Basic Information
| Provider Information | |||||||||
| NPI: | 1073804217 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CUSHING RAGON | ||||||||
| FirstName: | COLLEEN | ||||||||
| MiddleName: | SUSANNE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | APN, CNS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8940 N WOOD SAGE RD | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616157822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3092433000 | ||||||||
| FaxNumber: | 3092433274 | ||||||||
| Practice Location | |||||||||
| Address1: | 8940 N WOOD SAGE RD | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616157822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3092433000 | ||||||||
| FaxNumber: | 3092433274 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2011 | ||||||||
| LastUpdateDate: | 11/24/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SA2200X | 209.008764 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Adult Health | 363LF0000X | 209.013583 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 209.013583 | 01 | IL | LICENSE | OTHER |