Provider Demographics
NPI:1124706973
Name:WILSON, SUSANNAH ALYSE (NP)
Entity type:Individual
Prefix:
First Name:SUSANNAH
Middle Name:ALYSE
Last Name:WILSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 JEANSONNE ST
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71360-5060
Mailing Address - Country:US
Mailing Address - Phone:318-729-0501
Mailing Address - Fax:
Practice Address - Street 1:8585 PICARDY AVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-3748
Practice Address - Country:US
Practice Address - Phone:956-299-3727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-10
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA229744363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care