Basic Information
| Provider Information | |||||||||
| NPI: | 1679597876 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOVELACE | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 62063 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212642063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107065181 | ||||||||
| FaxNumber: | 4107065103 | ||||||||
| Practice Location | |||||||||
| Address1: | 22 S GREENE ST | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103286749 | ||||||||
| FaxNumber: | 4103286136 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 06/12/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080I0007X | R117678 | MD | N | Allopathic & Osteopathic Physicians | Pediatrics | Clinical & Laboratory Immunology | 363LP0200X | R117678 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 000290900 | 05 | MD | MEDICAID |