Provider Demographics
NPI:1497151732
Name:BRENNAN, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:BRENNAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:HERSHEY
Mailing Address - State:PA
Mailing Address - Zip Code:17033-2360
Mailing Address - Country:US
Mailing Address - Phone:800-243-1455
Mailing Address - Fax:
Practice Address - Street 1:4000 VINE ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:PA
Practice Address - Zip Code:17057-3565
Practice Address - Country:US
Practice Address - Phone:717-531-7260
Practice Address - Fax:717-531-0806
Is Sole Proprietor?:No
Enumeration Date:2014-11-14
Last Update Date:2014-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN004311133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered