Provider Demographics
NPI:1144279100
Name:WILDE, SUSAN (CNP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:WILDE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3707 DOTY RD
Mailing Address - Street 2:SUITE G
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-7530
Mailing Address - Country:US
Mailing Address - Phone:815-206-1067
Mailing Address - Fax:815-206-2804
Practice Address - Street 1:4309 W MEDICAL CENTER DR
Practice Address - Street 2:B310
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-8419
Practice Address - Country:US
Practice Address - Phone:815-344-0900
Practice Address - Fax:815-344-8957
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2007-08-31
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK38627Medicare PIN