Provider Demographics
NPI:1811092364
Name:LANGE, SUSAN ELAINE (CRNP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:ELAINE
Last Name:LANGE
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1126 OPAL CT
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-5940
Mailing Address - Country:US
Mailing Address - Phone:240-420-2666
Mailing Address - Fax:240-420-0951
Practice Address - Street 1:1126 OPAL CT
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-5940
Practice Address - Country:US
Practice Address - Phone:240-420-2666
Practice Address - Fax:240-420-0951
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR135100363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD002978500Medicaid
MDQ37206Medicare UPIN
MD002978500Medicaid