Basic Information
| Provider Information | |||||||||
| NPI: | 1073504759 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MACKIE-LEE | ||||||||
| FirstName: | SUSANNE | ||||||||
| MiddleName: | BLANCHETTE | ||||||||
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| Credential: | MD MPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1300 PICCARD DR | ||||||||
| Address2: | STE 202 | ||||||||
| City: | ROCKVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208504303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3019217900 | ||||||||
| FaxNumber: | 3019217915 | ||||||||
| Practice Location | |||||||||
| Address1: | 7500 IRON BAR LN | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 20155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037536772 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2005 | ||||||||
| LastUpdateDate: | 08/17/2019 | ||||||||
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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 | 208000000X | 0101055325 | VA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 006731911 | 05 | VA | MEDICAID |