Provider Demographics
NPI:1497966899
Name:DAVIS, SUZANNE M (RD, LDN, CDE)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:M
Last Name:DAVIS
Suffix:
Gender:F
Credentials:RD, LDN, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:NANTUCKET
Mailing Address - State:MA
Mailing Address - Zip Code:02554-2799
Mailing Address - Country:US
Mailing Address - Phone:508-825-8141
Mailing Address - Fax:508-825-8101
Practice Address - Street 1:57 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:NANTUCKET
Practice Address - State:MA
Practice Address - Zip Code:02554-2799
Practice Address - Country:US
Practice Address - Phone:508-825-8141
Practice Address - Fax:508-825-8101
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA659133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA659OtherLICENSE
MADY MT0145Medicare ID - Type Unspecified