Provider Demographics
NPI:1245846989
Name:CARL, SUSAN M (APN)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:CARL
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 E VOREY ST
Mailing Address - Street 2:
Mailing Address - City:HEYWORTH
Mailing Address - State:IL
Mailing Address - Zip Code:61745-9619
Mailing Address - Country:US
Mailing Address - Phone:309-838-8941
Mailing Address - Fax:
Practice Address - Street 1:201 NORTH UNIVERSITY STREET
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61790-0001
Practice Address - Country:US
Practice Address - Phone:309-438-8655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-18
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209021769363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily