Provider Demographics
NPI:1902848153
Name:DINTZIS, SUSANNAH NICHOLSON (FNP)
Entity Type:Individual
Prefix:
First Name:SUSANNAH
Middle Name:NICHOLSON
Last Name:DINTZIS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2214 N UNIVERSITY ST
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604-3221
Mailing Address - Country:US
Mailing Address - Phone:309-680-7669
Mailing Address - Fax:309-681-8443
Practice Address - Street 1:2321 N WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-5613
Practice Address - Country:US
Practice Address - Phone:309-680-7600
Practice Address - Fax:309-681-4681
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041283996363LP2300X
IL209-002547363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL7215059OtherBCBS PPO