Provider Demographics
NPI:1316212079
Name:STEVENSEN, SUSAN J (MED, LDN)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:J
Last Name:STEVENSEN
Suffix:
Gender:F
Credentials:MED, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2209 JACKSON TOWN RD
Mailing Address - Street 2:
Mailing Address - City:SPRUCE PINE
Mailing Address - State:NC
Mailing Address - Zip Code:28777-5637
Mailing Address - Country:US
Mailing Address - Phone:828-765-4365
Mailing Address - Fax:
Practice Address - Street 1:2209 JACKSON TOWN RD
Practice Address - Street 2:
Practice Address - City:SPRUCE PINE
Practice Address - State:NC
Practice Address - Zip Code:28777-5637
Practice Address - Country:US
Practice Address - Phone:828-765-4365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-14
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL001615133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist