Provider Demographics
NPI:1952491110
Name:NIEZGODA, SUSAN E (APN,CNS,PMHNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:E
Last Name:NIEZGODA
Suffix:
Gender:F
Credentials:APN,CNS,PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:UIC COLLEGE OF NURSING (MC802) 845 S. DAMEN AVE.
Mailing Address - Street 2:PMA DEPARTMENT, 9TH FLOOR
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-7350
Mailing Address - Country:US
Mailing Address - Phone:312-996-7996
Mailing Address - Fax:312-996-7725
Practice Address - Street 1:734 W 47TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60609-4411
Practice Address - Country:US
Practice Address - Phone:773-536-8400
Practice Address - Fax:773-536-2406
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0040030710OtherBC/BS
ILP75109Medicare UPIN
IL0040030710OtherBC/BS