MEDICARE: SUSAN JANE AKINS MSN RN BC AP MHCNS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	364S00000X	Clinical Nurse Specialist	048345	MO
2	364S00000X	Clinical Nurse Specialist	209004686	IL

General Provider Information

NPI Number	:	1790767721
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN JANE AKINS MSN RN BC AP MHCNS

Provider Business Mailing Address
First Line	:	2120 MADISON AVE
Second Line	:	STE 404
City	:	GRANITE CITY
State	:	IL
Zip	:	62040-4744
Country	:	US
Telephone Number	:	618-876-7515
Fax Number	:	618-876-7596

Provider Business Practice Location Address
First Line	:	3535 S JEFFERSON AVE
Second Line	:	SUITE 118
City	:	SAINT LOUIS
State	:	MO
Zip	:	63118-3930
Country	:	US
Telephone Number	:	314-776-7999
Fax Number	:	314-772-2257

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/16/2005
Last Update Date	:	12/18/2012

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