Provider Demographics
NPI:1376634980
Name:KLEMENHAGEN, SUSAN CARROLL (RD LD)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:CARROLL
Last Name:KLEMENHAGEN
Suffix:
Gender:F
Credentials:RD LD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:2355 OHIO
Mailing Address - Street 2:
Mailing Address - City:NORTH BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97459
Mailing Address - Country:US
Mailing Address - Phone:541-269-8182
Mailing Address - Fax:
Practice Address - Street 1:1775 THOMPSON RD
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420
Practice Address - Country:US
Practice Address - Phone:541-269-8182
Practice Address - Fax:541-266-7829
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
R116340Medicare UPIN
P92951Medicare UPIN