1336174093 NPI number — SUSAN E WILSON CPNP

Table of content: SUSAN E WILSON CPNP (NPI 1336174093)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336174093 NPI number — SUSAN E WILSON CPNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
SUSAN
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CPNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336174093
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
616 SMITHVIEW DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARYVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37803-6100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-379-2277
Provider Business Mailing Address Fax Number:
865-738-0087

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
616 SMITHVIEW DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARYVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37803-6100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-379-2277
Provider Business Practice Location Address Fax Number:
865-738-0087
Provider Enumeration Date:
07/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LN0005X , with the licence number:  APN12098 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 20060525 . This is a "BOARD CERTIFICATION #" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: APN0000012098 . This is a "ADVANCED PRACTICE ID #" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: RN0000096921 . This is a "RN STATE LICENSE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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