Provider Demographics
NPI:1437324720
Name:NICHOLSON, SUZANNE O (APN)
Entity Type:Individual
Prefix:MS
First Name:SUZANNE
Middle Name:O
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 FOXFIELD RD
Mailing Address - Street 2:STE 100
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-5799
Mailing Address - Country:US
Mailing Address - Phone:630-933-2550
Mailing Address - Fax:630-933-2558
Practice Address - Street 1:2900 FOXFIELD RD
Practice Address - Street 2:STE 100
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-5799
Practice Address - Country:US
Practice Address - Phone:630-933-2550
Practice Address - Fax:630-933-2558
Is Sole Proprietor?:No
Enumeration Date:2008-04-28
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-004466363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL820800OtherMEDICARE PTAN (GROUP)
IL820800062OtherMEDICARE PTAN (INDIVIDUAL)
ILIL5966OtherMEDICARE PTAN (GROUP)
ILIL7268005OtherMEDICARE PTAN (INDIVIDUAL)
ILIL5966002OtherMEDICARE PTAN (INDIVIDUAL)
ILIL5966002OtherMEDICARE PTAN (INDIVIDUAL)