Provider Demographics
NPI:1720574254
Name:VILLERS, SUSAN GAYLE (NP-C)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:GAYLE
Last Name:VILLERS
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:GAYLE
Other - Last Name:ESTEP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:97 GREAT TEAYS BLVD STE 6
Mailing Address - Street 2:
Mailing Address - City:SCOTT DEPOT
Mailing Address - State:WV
Mailing Address - Zip Code:25560-9816
Mailing Address - Country:US
Mailing Address - Phone:304-757-6999
Mailing Address - Fax:304-201-5019
Practice Address - Street 1:800 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25302-3351
Practice Address - Country:US
Practice Address - Phone:304-414-1880
Practice Address - Fax:304-414-1886
Is Sole Proprietor?:No
Enumeration Date:2018-07-09
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVF10171032208000000X
WVAPRN57336363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1720574254Medicaid