Provider Demographics
NPI:1285684035
Name:DAVIS, SUSAN (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:
Last Name:DAVIS
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 1:2401 W BELVEDERE AVE
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-5216
Mailing Address - Country:US
Mailing Address - Phone:410-601-5524
Mailing Address - Fax:410-601-8946
Practice Address - Street 1:2435 W BELVEDERE AVE
Practice Address - Street 2:SUITE 35
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-5224
Practice Address - Country:US
Practice Address - Phone:410-601-0900
Practice Address - Fax:410-601-0901
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR093098363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP00125781OtherR/R MEDICARE PROVIDER #
MDCC1918OtherR/R MEDICARE GROUP #
MD847MMedicare PIN
MD186850Y33Medicare PIN
MDCC1918OtherR/R MEDICARE GROUP #
MDS567F783Medicare PIN