Provider Demographics
NPI:1417169095
Name:MATTHEW, SUSAN CHACKO (ND APN FNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:CHACKO
Last Name:MATTHEW
Suffix:
Gender:F
Credentials:ND APN FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4906
Mailing Address - Country:US
Mailing Address - Phone:630-312-6304
Mailing Address - Fax:630-312-6667
Practice Address - Street 1:500 REMINGTON BLVD
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-4906
Practice Address - Country:US
Practice Address - Phone:630-312-6304
Practice Address - Fax:630-312-6667
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL41285306163W00000X
IL209002419363L00000X, 363LF0000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care