Provider Demographics
NPI:1679181176
Name:LUKWAGO, SUSAN N (RD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:N
Last Name:LUKWAGO
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 1:1330 N CAIN AVE
Mailing Address - Street 2:
Mailing Address - City:LIBERAL
Mailing Address - State:KS
Mailing Address - Zip Code:67901-2317
Mailing Address - Country:US
Mailing Address - Phone:620-626-4221
Mailing Address - Fax:
Practice Address - Street 1:1330 N CAIN AVE
Practice Address - Street 2:
Practice Address - City:LIBERAL
Practice Address - State:KS
Practice Address - Zip Code:67901-2317
Practice Address - Country:US
Practice Address - Phone:620-655-5494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-21
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1291133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered