Provider Demographics
NPI:1639787765
Name:DE LA FUENTE, SUSANA (RDN)
Entity Type:Individual
Prefix:MISS
First Name:SUSANA
Middle Name:
Last Name:DE LA FUENTE
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20347 NE 61ST CT
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98053-7824
Mailing Address - Country:US
Mailing Address - Phone:832-339-5482
Mailing Address - Fax:
Practice Address - Street 1:3020 RUCKER AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-3900
Practice Address - Country:US
Practice Address - Phone:425-339-5200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-15
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered