Provider Demographics
NPI:1083011449
Name:WILSON, SUSAN MARY (RN/LMT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARY
Last Name:WILSON
Suffix:
Gender:F
Credentials:RN/LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3024 N 125TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68164-2500
Mailing Address - Country:US
Mailing Address - Phone:402-680-0626
Mailing Address - Fax:
Practice Address - Street 1:11911 ARBOR ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-2970
Practice Address - Country:US
Practice Address - Phone:402-680-0626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-01
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1998225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist