Provider Demographics
NPI:1396764833
Name:LEWIS, SUSAN K
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:K
Last Name:LEWIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-1362
Mailing Address - Country:US
Mailing Address - Phone:541-963-8421
Mailing Address - Fax:541-963-1845
Practice Address - Street 1:900 SUNSET DR
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-1362
Practice Address - Country:US
Practice Address - Phone:541-963-8421
Practice Address - Fax:541-963-1845
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP88639Medicare UPIN
ORR115658Medicare ID - Type UnspecifiedMEDICARE