Basic Information
| Provider Information | |||||||||
| NPI: | 1518383264 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BIGHAM | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10319 CENTRAL PARK BLVD | ||||||||
| Address2: | |||||||||
| City: | HUNTLEY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601428187 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473879161 | ||||||||
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| Practice Location | |||||||||
| Address1: | 360 STATION DR | ||||||||
| Address2: | |||||||||
| City: | CRYSTAL LAKE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153386600 | ||||||||
| FaxNumber: | 8154558044 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2014 | ||||||||
| LastUpdateDate: | 12/26/2018 | ||||||||
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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 | 363LF0000X | 209011436 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 209011436 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 163W00000X | 041.353295 | IL | N | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 209011436 | 01 | IL | STATE LICENSE | OTHER |