Provider Demographics
NPI:1932506581
Name:SIGURDSON, SUSAN (RD, CDE)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:SIGURDSON
Suffix:
Gender:F
Credentials:RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2168
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58107-2168
Mailing Address - Country:US
Mailing Address - Phone:701-234-2119
Mailing Address - Fax:
Practice Address - Street 1:2400 32ND AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-5800
Practice Address - Country:US
Practice Address - Phone:701-234-8800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-25
Last Update Date:2015-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2205133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN710000112OtherMEDICARE PART B