Provider Demographics
NPI:1649210717
Name:CHISHOLM, SUSAN (RN, CRNP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:CHISHOLM
Suffix:
Gender:F
Credentials:RN, CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
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Mailing Address - Street 1:8028 RITCHIE HWY
Mailing Address - Street 2:SUITE 210B
Mailing Address - City:PASADENA
Mailing Address - State:MD
Mailing Address - Zip Code:21122-1075
Mailing Address - Country:US
Mailing Address - Phone:410-766-1995
Mailing Address - Fax:410-761-6095
Practice Address - Street 1:305 COLLEGE PKWY
Practice Address - Street 2:
Practice Address - City:ARNOLD
Practice Address - State:MD
Practice Address - Zip Code:21012-2912
Practice Address - Country:US
Practice Address - Phone:410-647-0015
Practice Address - Fax:410-647-0019
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDR107431363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD644565900Medicaid
MD644565900Medicaid
800LD762Medicare ID - Type Unspecified