MEDICARE: SUSAN CHISHOLM RN, CRNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	R107431	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1649210717
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN CHISHOLM RN, CRNP

Provider Business Mailing Address
First Line	:	8028 RITCHIE HWY
Second Line	:	SUITE 210B
City	:	PASADENA
State	:	MD
Zip	:	21122-1075
Country	:	US
Telephone Number	:	410-766-1995
Fax Number	:	410-761-6095

Provider Business Practice Location Address
First Line	:	305 COLLEGE PKWY
Second Line	:
City	:	ARNOLD
State	:	MD
Zip	:	21012-2912
Country	:	US
Telephone Number	:	410-647-0015
Fax Number	:	410-647-0019

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/07/2006
Last Update Date	:	12/02/2011

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