Provider Demographics
NPI:1699816504
Name:PEACOCK, SUSAN (MS,RD,LDN)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:
Last Name:PEACOCK
Suffix:
Gender:F
Credentials:MS,RD,LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 WATERWAY DR S APT 203
Mailing Address - Street 2:
Mailing Address - City:LANTANA
Mailing Address - State:FL
Mailing Address - Zip Code:33462-1827
Mailing Address - Country:US
Mailing Address - Phone:561-758-1734
Mailing Address - Fax:561-540-5186
Practice Address - Street 1:2240 W WOOLBRIGHT RD STE 305
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33426-6363
Practice Address - Country:US
Practice Address - Phone:561-758-1734
Practice Address - Fax:561-540-5186
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2022-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133V00000X
FLND3521133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE8796Medicare ID - Type UnspecifiedDIETITIAN