Provider Demographics
NPI:1508232950
Name:CLEGG, SUZANNE
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:CLEGG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SUZANNE
Other - Middle Name:
Other - Last Name:CLEGG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RD, LAC
Mailing Address - Street 1:85 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:LYNBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11563-2139
Mailing Address - Country:US
Mailing Address - Phone:516-823-2511
Mailing Address - Fax:
Practice Address - Street 1:85 WALNUT ST
Practice Address - Street 2:
Practice Address - City:LYNBROOK
Practice Address - State:NY
Practice Address - Zip Code:11563-2139
Practice Address - Country:US
Practice Address - Phone:516-823-2511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-19
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY573445133V00000X
NY000240171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered