Provider Demographics
NPI:1265488936
Name:LANG, SUSAN (CNM)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:LANG
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6708 N KNOXVILLE AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-2862
Mailing Address - Country:US
Mailing Address - Phone:309-691-6868
Mailing Address - Fax:309-691-6858
Practice Address - Street 1:6708 N KNOXVILLE AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-2862
Practice Address - Country:US
Practice Address - Phone:309-691-6868
Practice Address - Fax:309-691-6858
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILQ17157Medicare UPIN