Provider Demographics
NPI:1144325275
Name:ETTINGER, SUSAN W (MSN,NPC)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:W
Last Name:ETTINGER
Suffix:
Gender:F
Credentials:MSN,NPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6201 GREENLEIGH AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLE RIVER
Mailing Address - State:MD
Mailing Address - Zip Code:21220-2004
Mailing Address - Country:US
Mailing Address - Phone:410-933-5412
Mailing Address - Fax:
Practice Address - Street 1:2360 W JOPPA RD
Practice Address - Street 2:
Practice Address - City:LUTHERVILLE TIMONIUM
Practice Address - State:MD
Practice Address - Zip Code:21093-4624
Practice Address - Country:US
Practice Address - Phone:410-847-3535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA279604363L00000X
MDR078653363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0718126Medicaid
S71926Medicare UPIN
MA0718126Medicaid