Provider Demographics
NPI:1497931885
Name:AMICK-SUESS, DEBRA LYNN (RD, CDE)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:LYNN
Last Name:AMICK-SUESS
Suffix:
Gender:F
Credentials:RD, CDE
Other - Prefix:
Other - First Name:DEBRA
Other - Middle Name:LYNN
Other - Last Name:SUESS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RD, CDE
Mailing Address - Street 1:PO BOX 7849
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92513-7849
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:47923 OASIS ST
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-9788
Practice Address - Country:US
Practice Address - Phone:760-863-8265
Practice Address - Fax:760-863-8598
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-15
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA706587133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2041-0395OtherNCBDE
CA706587OtherCDR