Healthcare Provider Details

I. General information

NPI: 1104973569
Provider Name (Legal Business Name): SUSAN K CARLYLE CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 10/03/2023
Certification Date: 10/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9000 FRANKLIN SQUARE DR
BALTIMORE MD
21237-3901
US

IV. Provider business mailing address

1136 OLDFIELD POINT RD
ELKTON MD
21921-7234
US

V. Phone/Fax

Practice location:
  • Phone: 449-777-7179
  • Fax:
Mailing address:
  • Phone: 443-907-3090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberL6-0A00515
License Number StateDE
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR134290
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: