Provider Demographics
NPI:1588974026
Name:STEWART, SUSAN ELIZABETH (ANP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:ELIZABETH
Last Name:STEWART
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 SAINT ELIZABETH BLVD STE 2800
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1099
Mailing Address - Country:US
Mailing Address - Phone:618-233-6044
Mailing Address - Fax:618-233-5195
Practice Address - Street 1:3 ST. ELIZABETH'S BLVD.
Practice Address - Street 2:STE. 2800
Practice Address - City:O'FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1099
Practice Address - Country:US
Practice Address - Phone:618-233-6044
Practice Address - Fax:618-233-5195
Is Sole Proprietor?:No
Enumeration Date:2010-10-18
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.007628207RC0000X
IL209007628363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP01046089OtherRAILROAD
IL$$$$$$$$$001Medicaid
ILP01046089OtherRAILROAD
ILF400249758Medicare UPIN