Healthcare Provider Details

I. General information

NPI: 1982918926
Provider Name (Legal Business Name): SUSAN MARIE ANTOL R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2010
Last Update Date: 08/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 W LOMBARD ST SUITE 425B
BALTIMORE MD
21201-1512
US

IV. Provider business mailing address

655 W LOMBARD ST SUITE 425B
BALTIMORE MD
21201-1512
US

V. Phone/Fax

Practice location:
  • Phone: 410-706-5145
  • Fax: 410-706-0140
Mailing address:
  • Phone: 410-706-5145
  • Fax: 410-706-0140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License NumberR057831
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberR057831
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: