Provider Demographics
NPI:1710146634
Name:WELDON, SUZANNE STEVENS (RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:SUZANNE
Middle Name:STEVENS
Last Name:WELDON
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1102 W IBERIAN CT
Mailing Address - Street 2:
Mailing Address - City:GRANBURY
Mailing Address - State:TX
Mailing Address - Zip Code:76048-4374
Mailing Address - Country:US
Mailing Address - Phone:409-363-3899
Mailing Address - Fax:
Practice Address - Street 1:1102 W IBERIAN CT
Practice Address - Street 2:
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76048-4374
Practice Address - Country:US
Practice Address - Phone:409-363-3899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-05
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX963693133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX220096601Medicaid
TXTXB118194Medicare Oscar/Certification
TXP00911399Medicare PIN