Provider Demographics
NPI:1619209152
Name:SUSAN L. DELAGRANGE
Entity Type:Organization
Organization Name:SUSAN L. DELAGRANGE
Other - Org Name:SUSAN DELAGRANGE SOLE MBR
Other - Org Type:Other Name
Authorized Official - Title/Position:REGISTERED DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:DELAGRANGE
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RD
Authorized Official - Phone:260-433-3367
Mailing Address - Street 1:2607 BARRY KNOLL WAY
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1942
Mailing Address - Country:US
Mailing Address - Phone:260-433-3367
Mailing Address - Fax:260-637-5780
Practice Address - Street 1:2607 BARRY KNOLL WAY
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1942
Practice Address - Country:US
Practice Address - Phone:260-433-3367
Practice Address - Fax:260-637-5780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-09
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN910521133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN260690UUUMedicare PIN