Provider Demographics
NPI:1205988581
Name:WADE, SUSAN MARIE (RD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:WADE
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 1:444 BRUCE ST
Mailing Address - Street 2:
Mailing Address - City:YREKA
Mailing Address - State:CA
Mailing Address - Zip Code:96097-3450
Mailing Address - Country:US
Mailing Address - Phone:530-841-6212
Mailing Address - Fax:
Practice Address - Street 1:444 BRUCE ST
Practice Address - Street 2:
Practice Address - City:YREKA
Practice Address - State:CA
Practice Address - Zip Code:96097-3450
Practice Address - Country:US
Practice Address - Phone:530-841-6212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ45396Medicare UPIN