Provider Demographics
NPI:1912397456
Name:WAHLSTROM, SUSANNA BERNIER (FNP)
Entity Type:Individual
Prefix:
First Name:SUSANNA
Middle Name:BERNIER
Last Name:WAHLSTROM
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:SUSANNA
Other - Middle Name:BERNIER
Other - Last Name:BRAMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:347 ROCK ST
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-4783
Mailing Address - Country:US
Mailing Address - Phone:906-227-9119
Mailing Address - Fax:906-228-2469
Practice Address - Street 1:347 ROCK ST
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-4783
Practice Address - Country:US
Practice Address - Phone:906-227-9119
Practice Address - Fax:906-228-2469
Is Sole Proprietor?:No
Enumeration Date:2015-02-04
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704145513 3738661363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily