Provider Demographics
NPI:1003996786
Name:WILLYARD, SUSAN R (DIETITIAN)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:R
Last Name:WILLYARD
Suffix:
Gender:F
Credentials:DIETITIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 6TH AVE SE
Mailing Address - Street 2:UNION HOSPITAL
Mailing Address - City:MAYVILLE
Mailing Address - State:ND
Mailing Address - Zip Code:58257
Mailing Address - Country:US
Mailing Address - Phone:701-788-3800
Mailing Address - Fax:701-788-2145
Practice Address - Street 1:42 6TH AVE SE
Practice Address - Street 2:UNION HOSPITAL
Practice Address - City:MAYVILLE
Practice Address - State:ND
Practice Address - Zip Code:58257
Practice Address - Country:US
Practice Address - Phone:701-788-3800
Practice Address - Fax:701-788-2145
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND182133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
14397OtherBLUE SHIELD
14397OtherBLUE SHIELD