Provider Demographics
NPI:1417286048
Name:AYERSMAN, SUSAN (MS, CNS, CCN)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:
Last Name:AYERSMAN
Suffix:
Gender:F
Credentials:MS, CNS, CCN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10980 E SCOPA TRL
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85262-3597
Mailing Address - Country:US
Mailing Address - Phone:480-466-8887
Mailing Address - Fax:
Practice Address - Street 1:10980 E SCOPA TRL STE 3100
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85262-3597
Practice Address - Country:US
Practice Address - Phone:480-466-8887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-10
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ707091Medicaid
AZ707091Medicaid