Provider Demographics
NPI:1356316590
Name:WALLACE, SUZANNE LEA (NP)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:LEA
Last Name:WALLACE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SUZANNE
Other - Middle Name:LEA
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:801 S WASHINGTON ST FL 4
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540-7430
Mailing Address - Country:US
Mailing Address - Phone:630-600-0700
Mailing Address - Fax:630-600-0701
Practice Address - Street 1:801 S WASHINGTON ST FL 4
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-7430
Practice Address - Country:US
Practice Address - Phone:630-600-0700
Practice Address - Fax:630-600-0701
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209000508363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q24437Medicare UPIN