Basic Information
| Provider Information | |||||||||
| NPI: | 1326373457 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DECKER | ||||||||
| FirstName: | SUZANNE | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | APN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3375 N SEMINARY ST | ||||||||
| Address2: | |||||||||
| City: | GALESBURG | ||||||||
| State: | IL | ||||||||
| PostalCode: | 614011251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3093443161 | ||||||||
| FaxNumber: | 3093449623 | ||||||||
| Practice Location | |||||||||
| Address1: | 3375 N SEMINARY ST | ||||||||
| Address2: | |||||||||
| City: | GALESBURG | ||||||||
| State: | IL | ||||||||
| PostalCode: | 614011251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3093443161 | ||||||||
| FaxNumber: | 3093449623 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2009 | ||||||||
| LastUpdateDate: | 08/01/2013 | ||||||||
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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 | 363L00000X | 209007779 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1598759292 | 05 | IA | MEDICAID |