Provider Demographics
NPI:1336490333
Name:COPP, SUSAN (CNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:COPP
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5100 RELIABLE PKWY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60686-0051
Mailing Address - Country:US
Mailing Address - Phone:309-672-4809
Mailing Address - Fax:
Practice Address - Street 1:900 MAIN ST
Practice Address - Street 2:SUITE 600
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61602-1005
Practice Address - Country:US
Practice Address - Phone:309-671-8270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-01
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209009795363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner