Provider Demographics
NPI:1518225051
Name:AGNES, SUSAN MOFFATT (RD)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:MOFFATT
Last Name:AGNES
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 152
Mailing Address - Street 2:
Mailing Address - City:SIMSBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06070-0152
Mailing Address - Country:US
Mailing Address - Phone:860-413-3883
Mailing Address - Fax:860-413-3884
Practice Address - Street 1:29 KRIPES RD
Practice Address - Street 2:
Practice Address - City:EAST GRANBY
Practice Address - State:CT
Practice Address - Zip Code:06026-9669
Practice Address - Country:US
Practice Address - Phone:860-413-3883
Practice Address - Fax:860-413-3884
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-02
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT709473133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered