Provider Demographics
NPI:1871805648
Name:PARK, SUZANNE OLHA (CRNA)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:OLHA
Last Name:PARK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1121 LAKE COOK RD STE M
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015-5234
Mailing Address - Country:US
Mailing Address - Phone:847-945-4550
Mailing Address - Fax:
Practice Address - Street 1:701 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-1612
Practice Address - Country:US
Practice Address - Phone:708-681-7859
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-09
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041-336253163W00000X
IL209008274367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse