Provider Demographics
NPI:1740286988
Name:TUTTLE, SUSAN RENEE (APN)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:RENEE
Last Name:TUTTLE
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:SUSIE
Other - Middle Name:
Other - Last Name:TUTTLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:325 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:RED BUD
Mailing Address - State:IL
Mailing Address - Zip Code:62278-1105
Mailing Address - Country:US
Mailing Address - Phone:618-282-7373
Mailing Address - Fax:
Practice Address - Street 1:325 SPRING ST
Practice Address - Street 2:
Practice Address - City:RED BUD
Practice Address - State:IL
Practice Address - Zip Code:62278-1105
Practice Address - Country:US
Practice Address - Phone:618-282-7373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209003723363LA2200X
IL209.003723363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP38249Medicare UPIN
ILL97717Medicare ID - Type Unspecified