Provider Demographics
NPI:1609145234
Name:DAVIS, SUSAN M (ND, FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:M
Last Name:DAVIS
Suffix:
Gender:F
Credentials:ND, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:755 E. BOUGHTON RD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440
Mailing Address - Country:US
Mailing Address - Phone:630-783-2207
Mailing Address - Fax:
Practice Address - Street 1:755 E BOUGHTON RD
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-2250
Practice Address - Country:US
Practice Address - Phone:630-783-2207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-28
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209004410363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily