Provider Demographics
NPI:1871502369
Name:KOEPPE, SUSAN L (CNP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:KOEPPE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1051 W US ROUTE 6
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450-3349
Mailing Address - Country:US
Mailing Address - Phone:815-942-4875
Mailing Address - Fax:815-942-5046
Practice Address - Street 1:1051 W US ROUTE 6
Practice Address - Street 2:SUITE 100
Practice Address - City:MORRIS
Practice Address - State:IL
Practice Address - Zip Code:60450-3349
Practice Address - Country:US
Practice Address - Phone:815-942-4875
Practice Address - Fax:815-942-5046
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2009-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209004405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0739010005OtherMEDICARE NSC
IL0739010006OtherMEDICARE NSC
IL0739010008OtherMEDICARE NSC
ILCL7476OtherRAILROAD MEDICARE GROUP #
ILP00294919OtherRR MEDICARE
IL0739010001OtherMEDICARE NSC
IL209004405Medicaid
IL209004405Medicaid
ILK19840Medicare PIN
IL370830011Medicare PIN
IL0739010008OtherMEDICARE NSC
ILQ49504Medicare UPIN
IL0739010006OtherMEDICARE NSC
IL0739010001OtherMEDICARE NSC