Provider Demographics
NPI:1205844842
Name:WILSON, SUSAN B (NP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:B
Last Name:WILSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:420 E 2ND AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-3224
Mailing Address - Country:US
Mailing Address - Phone:706-509-3278
Mailing Address - Fax:706-509-4608
Practice Address - Street 1:134 E FAIRMOUNT AVE
Practice Address - Street 2:
Practice Address - City:CEDARTOWN
Practice Address - State:GA
Practice Address - Zip Code:30125-2706
Practice Address - Country:US
Practice Address - Phone:770-748-5212
Practice Address - Fax:770-748-2944
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA045387363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA50BBBGPMedicare ID - Type UnspecifiedMEDICARE
GAS10304Medicare UPIN