Provider Demographics
NPI:1255549572
Name:WILMOTH, SUSAN LYNNE (MHR)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:LYNNE
Last Name:WILMOTH
Suffix:
Gender:F
Credentials:MHR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 OAK TREE LN
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73130-3533
Mailing Address - Country:US
Mailing Address - Phone:405-414-4846
Mailing Address - Fax:
Practice Address - Street 1:10400 VINEYARD BLVD
Practice Address - Street 2:SUITE E
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-3829
Practice Address - Country:US
Practice Address - Phone:405-848-5620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator