Provider Demographics
NPI:1104563105
Name:WILSON, SUSAN C (PMHNP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:C
Last Name:WILSON
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 2ND ST N STE B
Mailing Address - Street 2:
Mailing Address - City:SAFETY HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34695-3566
Mailing Address - Country:US
Mailing Address - Phone:352-345-0530
Mailing Address - Fax:
Practice Address - Street 1:802 2ND ST N
Practice Address - Street 2:SUITE B
Practice Address - City:SAFETY HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34695
Practice Address - Country:US
Practice Address - Phone:352-345-0530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-19
Last Update Date:2024-03-15
Deactivation Date:2024-01-29
Deactivation Code:
Reactivation Date:2024-03-15
Provider Licenses
StateLicense IDTaxonomies
FL11019679363LP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health