Provider Demographics
NPI:1629363874
Name:LUNDGREN, SUSAN GENE (NMD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:GENE
Last Name:LUNDGREN
Suffix:
Gender:F
Credentials:NMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4251 S HIGUERA ST
Mailing Address - Street 2:STE 300
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-7700
Mailing Address - Country:US
Mailing Address - Phone:888-856-1925
Mailing Address - Fax:888-856-1925
Practice Address - Street 1:4251 S HIGUERA ST
Practice Address - Street 2:STE 300
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-7700
Practice Address - Country:US
Practice Address - Phone:888-856-1925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-16
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAND-595175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAND-595OtherNATUROPATHIC LICENSE