Provider Demographics
NPI:1164460176
Name:D'ANGELO-COOLEY, SUSANNE (RD)
Entity Type:Individual
Prefix:
First Name:SUSANNE
Middle Name:
Last Name:D'ANGELO-COOLEY
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 1:301 US ROUTE 1
Mailing Address - Street 2:BUILDING C
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-7609
Mailing Address - Country:US
Mailing Address - Phone:207-396-8600
Mailing Address - Fax:207-396-8632
Practice Address - Street 1:175 US ROUTE 1
Practice Address - Street 2:
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-9048
Practice Address - Country:US
Practice Address - Phone:207-885-7700
Practice Address - Fax:207-885-7701
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MED1336133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEP00658294Medicare PIN
MEMT0248Medicare PIN
MEMT024803Medicare PIN