Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | 209.007241 | IL |
N | 363LA2100X | Nurse Practitioner - Acute Care | 209-007241 | IL |
NPI | 1033362892 |
---|---|
Provider Name | Mrs. Susan N. Juliusson |
First Address | Peoria, IL 61615 |
Second Address | Peoria, IL 61615 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/10/2008 |
Last Update Date | 08/04/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
833120 | MEDICARE GROUP PTAN (01) | IL |