Provider Demographics
NPI:1134367576
Name:WILSON, SUSAN (FNP)
Entity type:Individual
Prefix:MS
First Name:SUSAN
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 1:1421 YOUNG ST
Mailing Address - Street 2:
Mailing Address - City:SAULT SAINTE MARIE
Mailing Address - State:MI
Mailing Address - Zip Code:49783-3041
Mailing Address - Country:US
Mailing Address - Phone:906-632-1988
Mailing Address - Fax:
Practice Address - Street 1:16700 S WATER TOWER DR
Practice Address - Street 2:
Practice Address - City:KINCHELOE
Practice Address - State:MI
Practice Address - Zip Code:49788-1637
Practice Address - Country:US
Practice Address - Phone:906-495-5339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-22
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704142100363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704142100OtherLICENSURE