Provider Demographics
NPI:1053368480
Name:FUNKE, SUSAN HEINZ (CNM)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:HEINZ
Last Name:FUNKE
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8110 MAPLE LAWN BLVD STE 235
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:MD
Mailing Address - Zip Code:20759-2694
Mailing Address - Country:US
Mailing Address - Phone:301-340-8339
Mailing Address - Fax:301-340-9027
Practice Address - Street 1:1165 IMPERIAL DRIVE
Practice Address - Street 2:SUITE 300
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740
Practice Address - Country:US
Practice Address - Phone:301-665-9098
Practice Address - Fax:301-665-9096
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDR144314363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD994LMedicare PIN
MD131910YYKMedicare PIN