Provider Demographics
NPI:1245237387
Name:ILLIKMAN, SUSAN R (NP)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:R
Last Name:ILLIKMAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5325 ELLIOTT DR
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-8633
Mailing Address - Country:US
Mailing Address - Phone:734-712-8000
Mailing Address - Fax:734-712-8010
Practice Address - Street 1:5325 ELLIOTT DR
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-8633
Practice Address - Country:US
Practice Address - Phone:734-712-8000
Practice Address - Fax:734-712-8010
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704199428363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0E01050OtherBCBS GROUP PIN
MI7451595OtherAETNA
MI5008604980OtherBCBS INDIVIDUAL PIN
MI0P01550Medicare PIN
MI7451595OtherAETNA
MI5008604980OtherBCBS INDIVIDUAL PIN