Basic Information
| Provider Information | |||||||||
| NPI: | 1205844842 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 420 E 2ND AVE | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301613224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065093278 | ||||||||
| FaxNumber: | 7065094608 | ||||||||
| Practice Location | |||||||||
| Address1: | 134 E FAIRMOUNT AVE | ||||||||
| Address2: | |||||||||
| City: | CEDARTOWN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301252706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707485212 | ||||||||
| FaxNumber: | 7707482944 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 045387 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.