Provider Demographics
NPI:1104973569
Name:CARLYLE, SUSAN K (CRNA)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:K
Last Name:CARLYLE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1136 OLDFIELD POINT RD
Mailing Address - Street 2:
Mailing Address - City:ELKTON
Mailing Address - State:MD
Mailing Address - Zip Code:21921-7234
Mailing Address - Country:US
Mailing Address - Phone:443-907-3090
Mailing Address - Fax:
Practice Address - Street 1:9000 FRANKLIN SQUARE DR
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21237-3901
Practice Address - Country:US
Practice Address - Phone:449-777-7179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEL6-0A00515367500000X
MDR134290367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD522PS452Medicaid
MD52-1969010OtherTAX ID