Provider Demographics
NPI:1437230950
Name:WILLSON, SUSAN (CNM)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:
Last Name:WILLSON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 ALAN ST
Mailing Address - Street 2:
Mailing Address - City:STONE RIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:12484-5117
Mailing Address - Country:US
Mailing Address - Phone:845-687-4807
Mailing Address - Fax:845-687-4807
Practice Address - Street 1:33 ALAN ST
Practice Address - Street 2:
Practice Address - City:STONE RIDGE
Practice Address - State:NY
Practice Address - Zip Code:12484-5117
Practice Address - Country:US
Practice Address - Phone:845-687-4807
Practice Address - Fax:845-687-4807
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF000549-1176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP35108Medicare UPIN
NYMDM 781Medicare ID - Type Unspecified