Provider Demographics
NPI:1831126085
Name:BROOKS, SUSAN PETTY (RD)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:PETTY
Last Name:BROOKS
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 1:22009 39TH PLACE SOUTH
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98032
Mailing Address - Country:US
Mailing Address - Phone:206-764-2253
Mailing Address - Fax:206-764-2628
Practice Address - Street 1:1660 S COLUMBIAN WAY
Practice Address - Street 2:S-119-NFS
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98108-1532
Practice Address - Country:US
Practice Address - Phone:206-764-2253
Practice Address - Fax:206-764-2628
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA706276133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA706276OtherAMERICAN DIETETIC ASSOC