Provider Demographics
NPI:1942325790
Name:MILLER, SUSAN A (RD,CD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:A
Last Name:MILLER
Suffix:
Gender:F
Credentials:RD,CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 SUN VALLEY DR STE 200
Mailing Address - Street 2:
Mailing Address - City:DELAFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53018-2318
Mailing Address - Country:US
Mailing Address - Phone:262-646-6426
Mailing Address - Fax:262-646-2498
Practice Address - Street 1:123 HOSPITAL DR
Practice Address - Street 2:STE 1004
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53098-3331
Practice Address - Country:US
Practice Address - Phone:920-206-0666
Practice Address - Fax:920-206-0688
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI535029133VN1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI718100002Medicare PIN
WIP58377Medicare UPIN