Provider Demographics
NPI:1073792644
Name:MANTERNACH, SUSAN MARIE (RD,LD,CDDE)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:MARIE
Last Name:MANTERNACH
Suffix:
Gender:F
Credentials:RD,LD,CDDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1560 UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52001-4790
Mailing Address - Country:US
Mailing Address - Phone:563-589-4899
Mailing Address - Fax:563-589-4897
Practice Address - Street 1:1560 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52001-4790
Practice Address - Country:US
Practice Address - Phone:563-589-4899
Practice Address - Fax:563-589-4897
Is Sole Proprietor?:No
Enumeration Date:2007-10-30
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00564133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic