Provider Demographics
NPI:1356185722
Name:SUST, STEPHANIE RENEE (RDN)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:RENEE
Last Name:SUST
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1768 EDGEMONT DR
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-3135
Mailing Address - Country:US
Mailing Address - Phone:805-914-8046
Mailing Address - Fax:
Practice Address - Street 1:1768 EDGEMONT DR
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-3135
Practice Address - Country:US
Practice Address - Phone:805-914-8046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-20
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA086360672133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered