Provider Demographics
NPI:1609095959
Name:PROULX, SUZANNE THERESA (RD)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:THERESA
Last Name:PROULX
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 741
Mailing Address - Street 2:
Mailing Address - City:GOFFSTOWN
Mailing Address - State:NH
Mailing Address - Zip Code:03045-0741
Mailing Address - Country:US
Mailing Address - Phone:603-540-0212
Mailing Address - Fax:
Practice Address - Street 1:360 ROUTE 101 STE 1
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:NH
Practice Address - Zip Code:03110-5033
Practice Address - Country:US
Practice Address - Phone:603-540-0212
Practice Address - Fax:888-990-0412
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH295133V00000X
MA812133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered