Provider Demographics
NPI:1528669397
Name:WISNIEWSKI, SUSAN LEIGH
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:LEIGH
Last Name:WISNIEWSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:655 SOLOMONS ISLAND RD N
Mailing Address - Street 2:
Mailing Address - City:PRINCE FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:20678-3915
Mailing Address - Country:US
Mailing Address - Phone:410-535-5974
Mailing Address - Fax:844-411-6252
Practice Address - Street 1:655 SOLOMONS ISLAND RD N
Practice Address - Street 2:
Practice Address - City:PRINCE FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:20678-3915
Practice Address - Country:US
Practice Address - Phone:410-535-5974
Practice Address - Fax:844-411-6252
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-06
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD11408183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist