Provider Demographics
NPI:1790805380
Name:WODZIEN-GATZIOLIS, SUSAN (CPNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:WODZIEN-GATZIOLIS
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 TOWER CT STE 100
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-3336
Mailing Address - Country:US
Mailing Address - Phone:847-244-1375
Mailing Address - Fax:847-244-1002
Practice Address - Street 1:2400 BELVIDERE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-6165
Practice Address - Country:US
Practice Address - Phone:847-377-8440
Practice Address - Fax:847-377-8808
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209006489363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL041183777OtherRN LICENSE
IL209006489OtherAPN LICENSE