Provider Demographics
NPI:1326055534
Name:CLARK, SUSAN MARIE (CRNP)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:MARIE
Last Name:CLARK
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 1:301 RANDOLPH ST
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:MD
Mailing Address - Zip Code:21629-1243
Mailing Address - Country:US
Mailing Address - Phone:410-479-4306
Mailing Address - Fax:410-479-1714
Practice Address - Street 1:301 RANDOLPH ST
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:MD
Practice Address - Zip Code:21629-1243
Practice Address - Country:US
Practice Address - Phone:410-479-4306
Practice Address - Fax:410-479-1714
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR157798363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD784381000Medicaid
MDT5880040OtherCF BC/BS GRP/GHMSI/BL CHO
207884OtherPRIORITY PARTNERS
MD521116591OtherMARYLAND PHYSICIANS CARE
MD521116591OtherTRICARE
MD521116591OtherINFORMED
766408OtherNCPPO
MD521116591OtherCOVENTRY
MD89583301OtherCAREFIRST BC/BS RENDERING
9924498OtherCIGNA
MD521116591OtherINFORMED
MD784381000Medicaid