Provider Demographics
NPI:1437430345
Name:HENNON, SUSAN LOUISE (RD, LD)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:LOUISE
Last Name:HENNON
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:MS
Other - First Name:SUSAN
Other - Middle Name:THAYER
Other - Last Name:HENNON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RD, LD
Mailing Address - Street 1:3005 BLUEBERRY HILLS RD S
Mailing Address - Street 2:
Mailing Address - City:JUNEAU
Mailing Address - State:AK
Mailing Address - Zip Code:99801-1989
Mailing Address - Country:US
Mailing Address - Phone:907-364-3293
Mailing Address - Fax:
Practice Address - Street 1:3245 HOSPITAL DRIVE
Practice Address - Street 2:SEARHC
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801
Practice Address - Country:US
Practice Address - Phone:907-364-4476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-06
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK3133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK3OtherSTATE OF ALASKA LICENSED DIETITIAN