Susan J Mack, RN, FNP

Primary specialty

Family Nurse PractitionerTaxonomy code 363LF0000X

License

209007907 Issued in IL

Practice address

929 Stacy Burk Drive
Flora, IL 62839

Phone

(618) 662-2191

NPI assigned

May 22, 2007

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Nurse Practitioner, Registered Nurse

State licenses

Interoperability endpoints

• Direct secure messaging: smack@yourcarecommunity.org

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1179792000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1462492800000",
    "number": "1396955316",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "608 N MAIN ST",
            "city": "FLORA",
            "state": "IL",
            "postal_code": "628391406",
            "telephone_number": "618-662-4246"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "929 STACY BURK DRIVE",
            "city": "FLORA",
            "state": "IL",
            "postal_code": "62839",
            "telephone_number": "618-662-2191"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "MACK",
        "first_name": "SUSAN",
        "middle_name": "J",
        "credential": "RN, FNP",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2007-05-22",
        "last_updated": "2016-05-06",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "MO",
            "license": "070430",
            "primary": false
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "IL",
            "license": "209007907",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "420123507",
            "state": "MO"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Family Nurse Practitioner in Flora, IL
• Providers in Flora, IL by specialty
• Family Nurse Practitioner in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 6, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.