Healthcare Provider Details

I. General information

NPI: 1578218400
Provider Name (Legal Business Name): PERES SUSANNA KORIE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2022
Last Update Date: 07/18/2024
Certification Date: 07/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9199 REISTERSTOWN RD STE 101B
OWINGS MILLS MD
21117-4513
US

IV. Provider business mailing address

9199 REISTERSTOWN RD STE 101B
OWINGS MILLS MD
21117-4513
US

V. Phone/Fax

Practice location:
  • Phone: 443-898-8160
  • Fax: 443-898-8916
Mailing address:
  • Phone: 443-898-8160
  • Fax: 443-898-8916

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR224466
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR224466
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR224466
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: