Provider Demographics
NPI:1992766372
Name:WILSON, ELAINE SUSAN (ARNP/CNM)
Entity type:Individual
Prefix:MRS
First Name:ELAINE
Middle Name:SUSAN
Last Name:WILSON
Suffix:
Gender:F
Credentials:ARNP/CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:238 COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:SHALIMAR
Mailing Address - State:FL
Mailing Address - Zip Code:32579-2216
Mailing Address - Country:US
Mailing Address - Phone:850-609-0454
Mailing Address - Fax:
Practice Address - Street 1:307 BOATNER RD
Practice Address - Street 2:FAMILY HEALTH CLINIC/96TH MDG, SUITE 114
Practice Address - City:EGLIN AFB
Practice Address - State:FL
Practice Address - Zip Code:32542-1391
Practice Address - Country:US
Practice Address - Phone:850-883-8763
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9201126363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology