Provider Demographics
NPI:1629466826
Name:KIM, SUSAN (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:
Last Name:KIM
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 1:1030 LIBERTY RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ELDERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21784-7941
Mailing Address - Country:US
Mailing Address - Phone:410-549-0900
Mailing Address - Fax:410-549-6121
Practice Address - Street 1:1030 LIBERTY RD
Practice Address - Street 2:SUITE 100
Practice Address - City:ELDERSBURG
Practice Address - State:MD
Practice Address - Zip Code:21784-7941
Practice Address - Country:US
Practice Address - Phone:410-549-0900
Practice Address - Fax:410-549-6121
Is Sole Proprietor?:No
Enumeration Date:2014-12-23
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR213300363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics