Healthcare Provider Details

I. General information

NPI: 1679597876
Provider Name (Legal Business Name): SUSAN B LOVELACE CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 06/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 S GREENE ST
BALTIMORE MD
21201
US

IV. Provider business mailing address

PO BOX 62063
BALTIMORE MD
21264-2063
US

V. Phone/Fax

Practice location:
  • Phone: 410-328-6749
  • Fax: 410-328-6136
Mailing address:
  • Phone: 410-706-5181
  • Fax: 410-706-5103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080I0007X
TaxonomyPediatric Clinical & Laboratory Immunology Physician
License NumberR117678
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberR117678
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: