Provider Demographics
NPI:1033213301
Name:SHULTZ, SUSAN T (MS FNP)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:T
Last Name:SHULTZ
Suffix:
Gender:F
Credentials:MS FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 WYMAN PARK DR
Mailing Address - Street 2:STE 359A
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21211
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2112 DUNDALK AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21222
Practice Address - Country:US
Practice Address - Phone:410-288-4800
Practice Address - Fax:410-288-2475
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR135328363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD718300300Medicaid
P56379Medicare UPIN
MD718300300Medicaid