Provider Demographics
NPI:1578772844
Name:NICHOLS, SUSAN ANN (MS,RD,CDE,CDN)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:ANN
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:MS,RD,CDE,CDN
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:A
Other - Last Name:SCARUPA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSRDCDECDN
Mailing Address - Street 1:6 ESSEX CT
Mailing Address - Street 2:
Mailing Address - City:WASHINGTONVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:10992-1365
Mailing Address - Country:US
Mailing Address - Phone:845-497-7496
Mailing Address - Fax:845-496-1187
Practice Address - Street 1:6 ESSEX CT
Practice Address - Street 2:
Practice Address - City:WASHINGTONVILLE
Practice Address - State:NY
Practice Address - Zip Code:10992-1365
Practice Address - Country:US
Practice Address - Phone:845-497-7496
Practice Address - Fax:845-496-1187
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000197133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered