Provider Demographics
NPI:1245792142
Name:WETZEL, SUSAN MARIE (RD LD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:WETZEL
Suffix:
Gender:F
Credentials:RD LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4531 SE BELMONT ST STE 100
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-1675
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4540 NE GLISAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2333
Practice Address - Country:US
Practice Address - Phone:503-215-5237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-01
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLD-D-10187943133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered