Provider Demographics
NPI:1629358718
Name:MCMANN, SUSAN L (ACNP-BC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:MCMANN
Suffix:
Gender:F
Credentials:ACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 BOARDMAN CANFIELD RD
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-4226
Mailing Address - Country:US
Mailing Address - Phone:330-629-2888
Mailing Address - Fax:330-629-8940
Practice Address - Street 1:1011 BOARDMAN CANFIELD RD
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-4226
Practice Address - Country:US
Practice Address - Phone:330-629-2888
Practice Address - Fax:330-629-8940
Is Sole Proprietor?:No
Enumeration Date:2011-08-22
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH12492-NP363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0063017Medicaid
OHH051075Medicare PIN