Provider Demographics
NPI:1255590360
Name:DOUGLAS, SUSAN AUSTIN (MS, RD, LD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:AUSTIN
Last Name:DOUGLAS
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 1:295 GERMANTOWN BEND CV
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-7238
Mailing Address - Country:US
Mailing Address - Phone:901-759-9337
Mailing Address - Fax:
Practice Address - Street 1:295 GERMANTOWN BEND CV
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-7238
Practice Address - Country:US
Practice Address - Phone:901-759-9337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-04
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLDN0000001941133V00000X
AR78133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
103I713625Medicare UPIN