Provider Demographics
NPI:1073504759
Name:MACKIE-LEE, SUSANNE BLANCHETTE (MD MPH)
Entity Type:Individual
Prefix:
First Name:SUSANNE
Middle Name:BLANCHETTE
Last Name:MACKIE-LEE
Suffix:
Gender:F
Credentials:MD MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 PICCARD DR
Mailing Address - Street 2:STE 202
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-4303
Mailing Address - Country:US
Mailing Address - Phone:301-921-7900
Mailing Address - Fax:301-921-7915
Practice Address - Street 1:7500 IRON BAR LN
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20155
Practice Address - Country:US
Practice Address - Phone:703-753-6772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2019-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101055325208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006731911Medicaid