Provider Demographics
NPI:1588182281
Name:RYAN, SUSANNE A (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:SUSANNE
Middle Name:A
Last Name:RYAN
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:SUSANNE
Other - Middle Name:A
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APN
Mailing Address - Street 1:17759 67TH CT.
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-4031
Mailing Address - Country:US
Mailing Address - Phone:815-405-6539
Mailing Address - Fax:847-719-2265
Practice Address - Street 1:2655 WARRENVILLE RD
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-5555
Practice Address - Country:US
Practice Address - Phone:708-518-4518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-01
Last Update Date:2024-06-06
Deactivation Date:2023-12-27
Deactivation Code:
Reactivation Date:2024-06-06
Provider Licenses
StateLicense IDTaxonomies
IL209016463363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209016463Medicaid
IL209016463Medicaid