Provider Demographics
NPI:1619092970
Name:RUDALAVAGE, SUSAN (NUTRITIONIST)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:RUDALAVAGE
Suffix:
Gender:F
Credentials:NUTRITIONIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:746 JEFFERSON AVENUE
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18510
Mailing Address - Country:US
Mailing Address - Phone:570-343-2383
Mailing Address - Fax:570-963-6133
Practice Address - Street 1:640 MADISON AVENUE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18510
Practice Address - Country:US
Practice Address - Phone:570-941-0630
Practice Address - Fax:570-941-0648
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN003044133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA092090KXPMedicare ID - Type Unspecified