Provider Demographics
NPI:1063452852
Name:HODGES, SUSAN ANN (CRNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ANN
Last Name:HODGES
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 62602
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-2602
Mailing Address - Country:US
Mailing Address - Phone:410-328-0711
Mailing Address - Fax:410-328-6896
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-328-0711
Practice Address - Fax:410-328-6896
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR072603363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD606686-01OtherBLUE CROSS/BLUE SHIELD
DE1063452852Medicaid
MD964900000Medicaid
MD964900000Medicaid
DE1063452852Medicaid
S60643Medicare UPIN