Provider Demographics
NPI:1922174754
Name:STROM, SUSAN LYNN (RD, LD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LYNN
Last Name:STROM
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 1:1117 BATTLECREEK RD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-2407
Mailing Address - Country:US
Mailing Address - Phone:678-479-2229
Mailing Address - Fax:
Practice Address - Street 1:1117 BATTLECREEK RD
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-2407
Practice Address - Country:US
Practice Address - Phone:678-479-2229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-24
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003609133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered