Provider Demographics
NPI:1902951841
Name:VALENTINE, SUE ANNE (APN/CNP)
Entity Type:Individual
Prefix:
First Name:SUE
Middle Name:ANNE
Last Name:VALENTINE
Suffix:
Gender:F
Credentials:APN/CNP
Other - Prefix:
Other - First Name:SUE
Other - Middle Name:ANNE
Other - Last Name:VALENTINE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APN/CNP
Mailing Address - Street 1:544 W PERSHING RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526
Mailing Address - Country:US
Mailing Address - Phone:217-876-8370
Mailing Address - Fax:
Practice Address - Street 1:544 W PERSHING RD
Practice Address - Street 2:SUITE A
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526
Practice Address - Country:US
Practice Address - Phone:217-872-2400
Practice Address - Fax:217-875-4680
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2017-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209001529363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL205433001Medicare PIN