Healthcare Provider Details

I. General information

NPI: 1194858266
Provider Name (Legal Business Name): SUSAN M MCMULLEN CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10701 NEW GEORGES CREEK RD SW
FROSTBURG MD
21532-1457
US

IV. Provider business mailing address

1 LAKESIDE LOOP
RIDGELEY WV
26753-9730
US

V. Phone/Fax

Practice location:
  • Phone: 301-689-3229
  • Fax: 301-689-1129
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberR137999
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number55378
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: