Provider Demographics
NPI:1043433576
Name:PARKS, SUSAN M (RD,CSSD,LDN,CPT)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:M
Last Name:PARKS
Suffix:
Gender:F
Credentials:RD,CSSD,LDN,CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2282 FIELD STONE DR
Mailing Address - Street 2:
Mailing Address - City:MENDOTA HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55120-1918
Mailing Address - Country:US
Mailing Address - Phone:651-592-7830
Mailing Address - Fax:651-405-3850
Practice Address - Street 1:7300 METRO BLVD
Practice Address - Street 2:SUITE 140
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55439-2303
Practice Address - Country:US
Practice Address - Phone:651-592-7830
Practice Address - Fax:651-405-3850
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNN153133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0063-0001350OtherMEDICA
MN400A3PAOtherBLUE CROSS BLUE SHIELD
MN710001180Medicare PIN