Healthcare Provider Details

I. General information

NPI: 1952334278
Provider Name (Legal Business Name): SUSAN WOLCOTT LM, CPM, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 06/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 S A ST
MOUNT SHASTA CA
96067
US

IV. Provider business mailing address

5105 PLUM AVE
MOUNT SHASTA CA
96067-9155
US

V. Phone/Fax

Practice location:
  • Phone: 562-334-5706
  • Fax: 626-610-3825
Mailing address:
  • Phone: 530-926-5395
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP1700X
TaxonomyPerinatal Registered Nurse
License Number619799
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number166
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: