Provider Demographics
NPI:1649679911
Name:LEWIS, SUSAN (MS, CN)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:MS, 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 872
Mailing Address - Street 2:
Mailing Address - City:WOODINVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98072-0872
Mailing Address - Country:US
Mailing Address - Phone:206-920-1973
Mailing Address - Fax:
Practice Address - Street 1:17924 140TH AVE NE STE 230
Practice Address - Street 2:
Practice Address - City:WOODINVILLE
Practice Address - State:WA
Practice Address - Zip Code:98072
Practice Address - Country:US
Practice Address - Phone:206-920-1973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-22
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANU60494244133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist