Provider Demographics
NPI:1336174093
Name:WILSON, SUSAN E (CPNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:E
Last Name:WILSON
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:616 SMITHVIEW DR
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37803-6100
Mailing Address - Country:US
Mailing Address - Phone:865-379-2277
Mailing Address - Fax:865-738-0087
Practice Address - Street 1:616 SMITHVIEW DR
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37803-6100
Practice Address - Country:US
Practice Address - Phone:865-379-2277
Practice Address - Fax:865-738-0087
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN12098363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN20060525OtherBOARD CERTIFICATION #
TNAPN0000012098OtherADVANCED PRACTICE ID #
TNRN0000096921OtherRN STATE LICENSE
TNRN0000096921OtherRN STATE LICENSE