Provider Demographics
NPI:1528207412
Name:WILLOUGHBY, SUSAN (APN CNM)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:WILLOUGHBY
Suffix:
Gender:F
Credentials:APN CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3825 HIGHLAND AVE
Mailing Address - Street 2:STE 2F
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-1552
Mailing Address - Country:US
Mailing Address - Phone:630-852-3762
Mailing Address - Fax:630-852-4087
Practice Address - Street 1:3825 HIGHLAND AVE
Practice Address - Street 2:STE 2F
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-1552
Practice Address - Country:US
Practice Address - Phone:630-852-3762
Practice Address - Fax:630-852-4087
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-17
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL209-0003099367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife