Provider Demographics
NPI:1114184652
Name:WILDWOOD, SUSAN (GCFT)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:
Last Name:WILDWOOD
Suffix:
Gender:F
Credentials:GCFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6502
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83707-6502
Mailing Address - Country:US
Mailing Address - Phone:208-383-0390
Mailing Address - Fax:204-343-3756
Practice Address - Street 1:2533 N 26TH ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-0308
Practice Address - Country:US
Practice Address - Phone:208-433-8365
Practice Address - Fax:208-343-3756
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-21
Last Update Date:2009-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist