Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 363L00000X | Nurse Practitioner | 209002933 | IL |
Y | 363LF0000X | Nurse Practitioner - Family Medicine | 277000186 | IL |
NPI | 1003808270 |
---|---|
Provider Name | Ms. Susan A Mack |
First Address | Des Plaines, IL 60016-1230 |
Second Address | Des Plaines, IL 60016-1230 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/08/2005 |
Last Update Date | 07/12/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
P44555 | (02) | IL |