Provider Demographics
NPI:1760442297
Name:RUNYAN, SUSAN MARY (REGISTERED DIETITIAN)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:MARY
Last Name:RUNYAN
Suffix:
Gender:F
Credentials:REGISTERED DIETITIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2594 CARRIE LYNN DR
Mailing Address - Street 2:
Mailing Address - City:NORTH POLE
Mailing Address - State:AK
Mailing Address - Zip Code:99705-5639
Mailing Address - Country:US
Mailing Address - Phone:907-488-2968
Mailing Address - Fax:
Practice Address - Street 1:354TH MEDICAL GROUP
Practice Address - Street 2:2630 CENTRAL AVE, SUITE 1M07
Practice Address - City:EIELSON AFB
Practice Address - State:AK
Practice Address - Zip Code:99702
Practice Address - Country:US
Practice Address - Phone:907-377-6662
Practice Address - Fax:907-377-1629
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK110133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered