Provider Demographics
NPI:1740278811
Name:PHELPS, SUSAN L (RD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:PHELPS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1900 BROTHER GEENEN WAY
Mailing Address - Street 2:SENIOR FRIENDSHIP CENTERS, INC.
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34236-7102
Mailing Address - Country:US
Mailing Address - Phone:941-556-3215
Mailing Address - Fax:941-955-8214
Practice Address - Street 1:1900 BROTHER GEENEN WAY
Practice Address - Street 2:SENIOR FRIENDSHIP CENTERS, INC.
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34236-7102
Practice Address - Country:US
Practice Address - Phone:941-556-3215
Practice Address - Fax:941-955-8214
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND01579133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLND01579OtherLICENSE
FLN0005BMedicare PIN