Provider Demographics
NPI:1366716854
Name:WILSON, SUSAN ELIZABETH (CPM)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:ELIZABETH
Last Name:WILSON
Suffix:
Gender:F
Credentials:CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5410 HILL CREST ST
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65074-1213
Mailing Address - Country:US
Mailing Address - Phone:573-230-6023
Mailing Address - Fax:573-378-5295
Practice Address - Street 1:5410 HILL CREST ST
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:MO
Practice Address - Zip Code:65074-1213
Practice Address - Country:US
Practice Address - Phone:573-230-6023
Practice Address - Fax:573-378-5295
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-29
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO09090028176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife