Provider Demographics
NPI:1326187634
Name:WILSON, SUZANNE VICTORIA (FNP)
Entity Type:Individual
Prefix:MRS
First Name:SUZANNE
Middle Name:VICTORIA
Last Name:WILSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MS
Other - First Name:SUZANNE
Other - Middle Name:VICTORIA
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:PO BOX 1728
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-0034
Mailing Address - Country:US
Mailing Address - Phone:678-689-1100
Mailing Address - Fax:706-612-1620
Practice Address - Street 1:771 OLD NORCROSS RD
Practice Address - Street 2:SUITE 135
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-4386
Practice Address - Country:US
Practice Address - Phone:678-689-1100
Practice Address - Fax:678-722-8206
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN159818NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA525719654AMedicaid
GA525719654AMedicaid