Healthcare Provider Details

I. General information

NPI: 1952665366
Provider Name (Legal Business Name): SUSAN PODRAZA KOPUNEK CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2012
Last Update Date: 03/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 S CATON AVE MS 235
BALTIMORE MD
21229-5201
US

IV. Provider business mailing address

900 S CATON AVE MS 235
BALTIMORE MD
21229-5201
US

V. Phone/Fax

Practice location:
  • Phone: 667-234-8777
  • Fax: 667-234-3517
Mailing address:
  • Phone: 667-234-8777
  • Fax: 667-234-3517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberR120298
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: