Provider Demographics
NPI:1295861235
Name:HERRON, SUSAN CAROLINE (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:CAROLINE
Last Name:HERRON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:MS
Other - First Name:SUSAN
Other - Middle Name:CAROLINE
Other - Last Name:NELSON-WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:3510 OLD WASHINGTON ROAD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20602
Mailing Address - Country:US
Mailing Address - Phone:301-932-5890
Mailing Address - Fax:301-645-6361
Practice Address - Street 1:3510 OLD WASHINGTON ROAD
Practice Address - Street 2:SUITE 100
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602
Practice Address - Country:US
Practice Address - Phone:301-932-5890
Practice Address - Fax:301-645-6361
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR070218363LA2200X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDQ09075Medicare UPIN