Provider Demographics
NPI:1295945574
Name:ROBERTS, SUE ELLEN (MPH MS RD CN)
Entity type:Individual
Prefix:
First Name:SUE
Middle Name:ELLEN
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:MPH MS RD CN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4354
Mailing Address - Street 2:
Mailing Address - City:WEST RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99353-4005
Mailing Address - Country:US
Mailing Address - Phone:509-392-2071
Mailing Address - Fax:309-401-8759
Practice Address - Street 1:1625 BUTTERNUT AVE
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99354-2743
Practice Address - Country:US
Practice Address - Phone:509-392-2071
Practice Address - Fax:309-401-8759
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANU00001772133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered