Provider Demographics
NPI:1578535779
Name:WILSON, SUZANNE (FNP)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 NORTH CAYUGA STREET
Mailing Address - Street 2:ITHACAMED
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-4219
Mailing Address - Country:US
Mailing Address - Phone:607-277-0969
Mailing Address - Fax:607-277-3242
Practice Address - Street 1:404 NORTH CAYUGA ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-4219
Practice Address - Country:US
Practice Address - Phone:607-277-0969
Practice Address - Fax:607-277-3242
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY416301-1163W00000X
NYF336792363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse