Provider Demographics
NPI:1518148071
Name:BROECKELMAN, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:BROECKELMAN
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 1:100 CRESTVUE AVE
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:KS
Mailing Address - Zip Code:66956-2407
Mailing Address - Country:US
Mailing Address - Phone:785-378-3137
Mailing Address - Fax:
Practice Address - Street 1:100 CRESTVUE AVE
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:KS
Practice Address - Zip Code:66956-2407
Practice Address - Country:US
Practice Address - Phone:785-378-3137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-26
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS829133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
708146OtherCDR ID NUMBER