Provider Demographics
NPI:1679550420
Name:PAVLICK, SUSAN C (RN-C, FNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:C
Last Name:PAVLICK
Suffix:
Gender:F
Credentials:RN-C, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2377 BLOOMINGTON AVENUE
Mailing Address - Street 2:SUITE B
Mailing Address - City:STREATOR
Mailing Address - State:IL
Mailing Address - Zip Code:61364-1307
Mailing Address - Country:US
Mailing Address - Phone:815-672-1382
Mailing Address - Fax:
Practice Address - Street 1:2377 BLOOMINGTON AVENUE
Practice Address - Street 2:SUITE B
Practice Address - City:STREATOR
Practice Address - State:IL
Practice Address - Zip Code:61364-1307
Practice Address - Country:US
Practice Address - Phone:815-672-1382
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF330105363LF0000X
IL209009636363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP02313Medicare UPIN