Provider Demographics
NPI:1003808270
Name:MACK, SUSAN A (APRN-FPA)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:A
Last Name:MACK
Suffix:
Gender:F
Credentials:APRN-FPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:514 TEELA LN
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-1230
Mailing Address - Country:US
Mailing Address - Phone:847-692-6000
Mailing Address - Fax:847-692-6112
Practice Address - Street 1:514 TEELA LN
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016-1230
Practice Address - Country:US
Practice Address - Phone:847-692-6000
Practice Address - Fax:847-692-6112
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL277000186363LF0000X
IL209002933363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP44555Medicare UPIN