Provider Demographics
NPI:1306583778
Name:SUMIDA, COURTNEY (DNP, AGPCNP-BC, CSFA)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:SUMIDA
Suffix:
Gender:F
Credentials:DNP, AGPCNP-BC, CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 E HUEBBE PKWY
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-1896
Mailing Address - Country:US
Mailing Address - Phone:608-364-2230
Mailing Address - Fax:608-363-7394
Practice Address - Street 1:1905 E HUEBBE PKWY
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-1896
Practice Address - Country:US
Practice Address - Phone:608-364-2230
Practice Address - Fax:608-363-7394
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-17
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041442675163W00000X
IL209.026121363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163W00000XNursing Service ProvidersRegistered Nurse