Provider Demographics
NPI:1194858266
Name:MCMULLEN, SUSAN M (CRNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:MCMULLEN
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 1:1 LAKESIDE LOOP
Mailing Address - Street 2:
Mailing Address - City:RIDGELEY
Mailing Address - State:WV
Mailing Address - Zip Code:26753-9730
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10701 NEW GEORGES CREEK RD SW
Practice Address - Street 2:
Practice Address - City:FROSTBURG
Practice Address - State:MD
Practice Address - Zip Code:21532-1457
Practice Address - Country:US
Practice Address - Phone:301-689-3229
Practice Address - Fax:301-689-1129
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR137999363LA2200X
WV55378363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health