Provider Demographics
NPI:1154614048
Name:MAGENHEIMER, SUSAN G (CNM)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:G
Last Name:MAGENHEIMER
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224-D CORNWALL STREET, NW, SUITE 403
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-2704
Mailing Address - Country:US
Mailing Address - Phone:703-737-6010
Mailing Address - Fax:703-443-8643
Practice Address - Street 1:19455 DEERFIELD AVENUE, SUITE 204
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-8102
Practice Address - Country:US
Practice Address - Phone:703-858-1500
Practice Address - Fax:703-858-5022
Is Sole Proprietor?:No
Enumeration Date:2011-05-25
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1022120367A00000X
VA0024165070176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1154614048Medicaid
VA30016809680001Medicaid