Provider Demographics
NPI:1619215225
Name:CLARK, SUSAN (RN, CDE)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:RN, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5601 LOCH RAVEN BLVD
Mailing Address - Street 2:GOOD HEALTH CENTER, O'NEIL BLDG 2ND FL
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21239-2945
Mailing Address - Country:US
Mailing Address - Phone:443-444-4550
Mailing Address - Fax:
Practice Address - Street 1:5601 LOCH RAVEN BLVD
Practice Address - Street 2:GOOD HEALTH CENTER, O'NEIL BLDG 2ND FL
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21239-2945
Practice Address - Country:US
Practice Address - Phone:443-444-4550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-17
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDRN144178163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator