Provider Demographics
NPI:1871245175
Name:O'NEALE-WILLSON, SUZANNE LEE
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:LEE
Last Name:O'NEALE-WILLSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1342 WASHINGTON DR
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21403-4731
Mailing Address - Country:US
Mailing Address - Phone:410-980-3564
Mailing Address - Fax:
Practice Address - Street 1:901 ELKRIDGE LANDING RD STE 360
Practice Address - Street 2:
Practice Address - City:LINTHICUM
Practice Address - State:MD
Practice Address - Zip Code:21090-2920
Practice Address - Country:US
Practice Address - Phone:443-384-0170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-19
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDF08211039363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily