Provider Demographics
NPI:1629057567
Name:FREBURG, SUSAN G (ARNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:G
Last Name:FREBURG
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:G
Other - Last Name:STONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:2300 53RD AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-7564
Mailing Address - Country:US
Mailing Address - Phone:563-322-0971
Mailing Address - Fax:563-324-0615
Practice Address - Street 1:2300 53RD AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-7564
Practice Address - Country:US
Practice Address - Phone:563-322-0971
Practice Address - Fax:563-324-0615
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2011-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAJ099839363LA2200X
IL041206933363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAIA0186OtherJOHN DEERE FAMILY
ILIL01C3OtherJOHN DEERE FAMILY
235860OtherMIDLANDS CHOICE
IA34055OtherWELLMARK
IL95015OtherWELLMARK
165227OtherIA HEALTH SOLUTIONS
IL8121085OtherBCBS
IAP00002855OtherRR MEDICARE
IAIA0186OtherJOHN DEERE FAMILY
P14113Medicare UPIN
235860OtherMIDLANDS CHOICE