Provider Demographics
NPI:1235325754
Name:DISHER, SUSAN ANN (RD CD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ANN
Last Name:DISHER
Suffix:
Gender:F
Credentials:RD CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1404 MEADOW LARK BLVD
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:IN
Mailing Address - Zip Code:46580-2041
Mailing Address - Country:US
Mailing Address - Phone:574-292-2337
Mailing Address - Fax:
Practice Address - Street 1:1404 MEADOW LARK BLVD
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46580-2041
Practice Address - Country:US
Practice Address - Phone:574-292-2337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-18
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37001356A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered