Provider Demographics
NPI:1720164320
Name:OUELLETTE, SUSAN (APRN)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:
Last Name:OUELLETTE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2124 RAMONA LN
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:MD
Mailing Address - Zip Code:21163-1248
Mailing Address - Country:US
Mailing Address - Phone:410-236-9951
Mailing Address - Fax:
Practice Address - Street 1:2124 RAMONA LN
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:MD
Practice Address - Zip Code:21163-1248
Practice Address - Country:US
Practice Address - Phone:410-236-9951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN00000363LP0808X
CT003720363LP0808X
MDR117618363LP0808X
MA0386509363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD61087301-PR31OtherCAREFIRST
MD772103000Medicaid
MD537442000OtherMAGELLAN
MDM644-0001OtherBLUE CROSS/BLUE SHIELD
MD015LM670OtherMEDICARE NUMBER URBAN BEHAVIORAL ASSOCIATES
MD537442000OtherMAGELLAN
MD772103000Medicaid