Provider Demographics
NPI:1649287293
Name:GIBBONS, SUSANNE W (CRNP)
Entity type:Individual
Prefix:
First Name:SUSANNE
Middle Name:W
Last Name:GIBBONS
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:SUSANNE
Other - Middle Name:W
Other - Last Name:SCHARNHORST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:8186 LARK BROWN ROAD
Mailing Address - Street 2:STE 201
Mailing Address - City:ELKRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21075
Mailing Address - Country:US
Mailing Address - Phone:410-730-3399
Mailing Address - Fax:410-740-4744
Practice Address - Street 1:5457 TWIN KNOLLS RD STE 100
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-3263
Practice Address - Country:US
Practice Address - Phone:410-689-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR093831363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
S03778Medicare UPIN
898LMedicare ID - Type Unspecified