Provider Demographics
NPI:1255755054
Name:LEWIS, SUZANNE (MS, RD,CD)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:MS, RD,CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1761 S 500 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-2901
Mailing Address - Country:US
Mailing Address - Phone:801-918-5823
Mailing Address - Fax:
Practice Address - Street 1:1761 S 500 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84105-2901
Practice Address - Country:US
Practice Address - Phone:801-918-5823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-13
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6134883-4901133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered