Provider Demographics
NPI:1578162202
Name:FAYCURRY, SUZANNA
Entity Type:Individual
Prefix:
First Name:SUZANNA
Middle Name:
Last Name:FAYCURRY
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 1:111 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:BARRINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:60010-3282
Mailing Address - Country:US
Mailing Address - Phone:847-224-6168
Mailing Address - Fax:
Practice Address - Street 1:111 NORTH AVE
Practice Address - Street 2:
Practice Address - City:BARRINGTON
Practice Address - State:IL
Practice Address - Zip Code:60010-3282
Practice Address - Country:US
Practice Address - Phone:847-224-6168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-23
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86062607133N00000X, 133VN1004X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric