Provider Demographics
NPI:1013102722
Name:STARK, SUSAN AUDREY (MS, RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:AUDREY
Last Name:STARK
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 LOTHROP ST
Mailing Address - Street 2:SCAIFE HALL SUITE S 1105.1
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15213-2536
Mailing Address - Country:US
Mailing Address - Phone:412-647-2906
Mailing Address - Fax:412-647-7839
Practice Address - Street 1:3459 5TH AVE
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15213-3236
Practice Address - Country:US
Practice Address - Phone:412-647-2906
Practice Address - Fax:412-647-7839
Is Sole Proprietor?:No
Enumeration Date:2007-09-06
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN 000296133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA070362RTUMedicare PIN