Provider Demographics
NPI:1952334278
Name:WOLCOTT, SUSAN (LM, CPM, RN)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:WOLCOTT
Suffix:
Gender:F
Credentials:LM, CPM, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5105 PLUM AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT SHASTA
Mailing Address - State:CA
Mailing Address - Zip Code:96067-9155
Mailing Address - Country:US
Mailing Address - Phone:530-926-5395
Mailing Address - Fax:
Practice Address - Street 1:703 S A ST
Practice Address - Street 2:
Practice Address - City:MOUNT SHASTA
Practice Address - State:CA
Practice Address - Zip Code:96067
Practice Address - Country:US
Practice Address - Phone:562-334-5706
Practice Address - Fax:626-610-3825
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA619799163WP1700X
CA166176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No163WP1700XNursing Service ProvidersRegistered NursePerinatal