1790805380 NPI number — SUSAN WODZIEN-GATZIOLIS CPNP

Table of content: SUSAN WODZIEN-GATZIOLIS CPNP (NPI 1790805380)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790805380 NPI number — SUSAN WODZIEN-GATZIOLIS CPNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WODZIEN-GATZIOLIS
Provider First Name:
SUSAN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CPNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790805380
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15 TOWER CT STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GURNEE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60031-3336
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-244-1375
Provider Business Mailing Address Fax Number:
847-244-1002

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2400 BELVIDERE RD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
WAUKEGAN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60085-6165
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-377-8440
Provider Business Practice Location Address Fax Number:
847-377-8808
Provider Enumeration Date:
03/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0200X , with the licence number:  209006489 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 041183777 . This is a "RN LICENSE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 209006489 . This is a "APN LICENSE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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