Provider Demographics
NPI:1518941103
Name:OBENRADER, SUZANNE MARIE (CRNP RN)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:MARIE
Last Name:OBENRADER
Suffix:
Gender:F
Credentials:CRNP RN
Other - Prefix:
Other - First Name:SUZANNE
Other - Middle Name:MARIE
Other - Last Name:GOETZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 820933
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-0933
Mailing Address - Country:US
Mailing Address - Phone:215-540-8408
Mailing Address - Fax:215-540-8418
Practice Address - Street 1:515 PENNSYLVANIA AVE
Practice Address - Street 2:2ND FL SUITE A
Practice Address - City:FORT WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:19034-3314
Practice Address - Country:US
Practice Address - Phone:215-540-8404
Practice Address - Fax:215-540-8418
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2013-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN18636FL163W00000X
PAUP000800H363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA574399OtherCOVENTRY HEALTH AMERICA
PA30019410OtherKMHP
PA145531JTQMedicare PIN
P04143Medicare UPIN