Provider Demographics
NPI:1740518604
Name:ASHFORD TUCKER, SUSAN MARIE (MS, RD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:ASHFORD TUCKER
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1219 ELM ST
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864
Mailing Address - Country:US
Mailing Address - Phone:406-570-8019
Mailing Address - Fax:208-263-9747
Practice Address - Street 1:1219 ELM ST
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864
Practice Address - Country:US
Practice Address - Phone:406-570-8019
Practice Address - Fax:208-263-9747
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-03
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT517257133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered