Provider Demographics
NPI:1326249426
Name:LACAGNINA, SUSANNAH (RD MPH CDE)
Entity Type:Individual
Prefix:MS
First Name:SUSANNAH
Middle Name:
Last Name:LACAGNINA
Suffix:
Gender:F
Credentials:RD MPH CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2431 3RD STREET
Mailing Address - Street 2:UNIT ONE
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405
Mailing Address - Country:US
Mailing Address - Phone:310-581-9660
Mailing Address - Fax:310-392-6417
Practice Address - Street 1:2701 OCEAN PARK BLVD
Practice Address - Street 2:SUITE 130
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90405
Practice Address - Country:US
Practice Address - Phone:310-581-9660
Practice Address - Fax:310-392-6417
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL727882133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMNT727882Medicare ID - Type Unspecified