Provider Demographics
NPI:1932456704
Name:HARRIS, SUSAN (CRNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:HARRIS
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:CLISHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:4111 LOWER BECKLEYSVILLE RD
Mailing Address - Street 2:STE C
Mailing Address - City:HAMPSTEAD
Mailing Address - State:MD
Mailing Address - Zip Code:21074-2248
Mailing Address - Country:US
Mailing Address - Phone:410-374-0808
Mailing Address - Fax:
Practice Address - Street 1:4231 N WOODS TRL
Practice Address - Street 2:
Practice Address - City:HAMPSTEAD
Practice Address - State:MD
Practice Address - Zip Code:21074-3128
Practice Address - Country:US
Practice Address - Phone:410-374-9391
Practice Address - Fax:410-374-1866
Is Sole Proprietor?:No
Enumeration Date:2012-08-10
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR173590363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD218599Medicare PIN