Provider Demographics
NPI:1326111295
Name:MCKEOWN, SUSAN M (ARNP)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:M
Last Name:MCKEOWN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1245 ELM STREET
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03101-1308
Mailing Address - Country:US
Mailing Address - Phone:603-668-6629
Mailing Address - Fax:603-622-7680
Practice Address - Street 1:1245 ELM STREET
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03101-1308
Practice Address - Country:US
Practice Address - Phone:603-668-6629
Practice Address - Fax:603-622-7680
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH016062 21363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30008740Medicaid