=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710472527
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN SAINA STUBBS CRNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2018
-----------------------------------------------------
Last Update Date | 06/25/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 954 FORREST ST
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21202-4236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-230-1542
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5017 TARTAN HILL RD
-----------------------------------------------------
City | PERRY HALL
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21128-9639
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-902-6314
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | R187931
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------