Provider Demographics
NPI:1245362656
Name:DODGE, SUSAN ELIZABETH (CNM)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:ELIZABETH
Last Name:DODGE
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2146 HALLMARK DR
Mailing Address - Street 2:
Mailing Address - City:GAMBRILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21054-2127
Mailing Address - Country:US
Mailing Address - Phone:301-928-3485
Mailing Address - Fax:
Practice Address - Street 1:2146 HALLMARK DRIVE
Practice Address - Street 2:
Practice Address - City:GAMBRILLS
Practice Address - State:MD
Practice Address - Zip Code:21054-2127
Practice Address - Country:US
Practice Address - Phone:301-928-3485
Practice Address - Fax:410-451-0057
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2009-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024165401367A00000X
MDR147704367A00000X
DCRN964344367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAG01647B04Medicare ID - Type UnspecifiedINDIVIDUAL NUMBER