Provider Demographics
NPI:1053698340
Name:TAYLOR, SUSAN LEIGH (NP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:LEIGH
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:LEIGH
Other - Last Name:FLECKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:2650 RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1718
Mailing Address - Country:US
Mailing Address - Phone:847-657-1900
Mailing Address - Fax:847-733-5299
Practice Address - Street 1:2650 RIDGE AVE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-1718
Practice Address - Country:US
Practice Address - Phone:847-657-1900
Practice Address - Fax:847-733-5299
Is Sole Proprietor?:No
Enumeration Date:2011-11-15
Last Update Date:2013-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209009095363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health