Provider Demographics
NPI:1598887929
Name:SUNDERLAND, SUSANNAH (LAC)
Entity Type:Individual
Prefix:
First Name:SUSANNAH
Middle Name:
Last Name:SUNDERLAND
Suffix:
Gender:F
Credentials:LAC
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 130638
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92013-0638
Mailing Address - Country:US
Mailing Address - Phone:760-688-8814
Mailing Address - Fax:760-683-6944
Practice Address - Street 1:317 N EL CAMINO REAL
Practice Address - Street 2:SUITE 401
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-2811
Practice Address - Country:US
Practice Address - Phone:760-688-8814
Practice Address - Fax:760-683-6944
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-05
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10926171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist