Provider Demographics
NPI:1083867931
Name:WARE, SUZANNE O (RD)
Entity Type:Individual
Prefix:MRS
First Name:SUZANNE
Middle Name:O
Last Name:WARE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 MEDICAL DR # 201
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84112-1100
Mailing Address - Country:US
Mailing Address - Phone:801-581-8578
Mailing Address - Fax:
Practice Address - Street 1:85 MEDICAL DR # 201
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84112-1100
Practice Address - Country:US
Practice Address - Phone:801-581-8578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-23
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT100242-4901133VN1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT005703601Medicare PIN