1992766372 NPI number — MRS. ELAINE SUSAN WILSON ARNP/CNM

Table of content: MRS. ELAINE SUSAN WILSON ARNP/CNM (NPI 1992766372)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992766372 NPI number — MRS. ELAINE SUSAN WILSON ARNP/CNM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
ELAINE
Provider Middle Name:
SUSAN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
ARNP/CNM
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:
1992766372
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
238 COUNTRY CLUB RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHALIMAR
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32579-2216
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-609-0454
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
307 BOATNER RD
Provider Second Line Business Practice Location Address:
FAMILY HEALTH CLINIC/96TH MDG, SUITE 114
Provider Business Practice Location Address City Name:
EGLIN AFB
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32542-1391
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-883-8763
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/28/2006

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: 363LX0001X , with the licence number:  ARNP9201126 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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