Provider Demographics
NPI:1891779492
Name:LORD, SUSAN R (NP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:R
Last Name:LORD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 866
Mailing Address - Street 2:
Mailing Address - City:ROCKLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04841-0866
Mailing Address - Country:US
Mailing Address - Phone:207-594-3114
Mailing Address - Fax:207-594-3108
Practice Address - Street 1:22 WHITE ST
Practice Address - Street 2:
Practice Address - City:ROCKLAND
Practice Address - State:ME
Practice Address - Zip Code:04841-2978
Practice Address - Country:US
Practice Address - Phone:207-594-3114
Practice Address - Fax:207-594-3108
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MER-023932363LF0000X, 363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME286210099Medicaid