Provider Demographics
NPI:1528410735
Name:WILSON, SUSAN (NP-C)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4553 BIRMINGHAM WAY
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-8406
Mailing Address - Country:US
Mailing Address - Phone:919-250-4570
Mailing Address - Fax:919-250-4581
Practice Address - Street 1:10 SUNNYBROOK RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-1808
Practice Address - Country:US
Practice Address - Phone:919-250-4570
Practice Address - Fax:919-250-4581
Is Sole Proprietor?:No
Enumeration Date:2016-07-12
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCF06161819363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily