Provider Demographics
NPI:1780879759
Name:MILLER, SUSAN (RD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 BEACH HILL DR
Mailing Address - Street 2:
Mailing Address - City:FORT SALONGA
Mailing Address - State:NY
Mailing Address - Zip Code:11768-1423
Mailing Address - Country:US
Mailing Address - Phone:631-896-3240
Mailing Address - Fax:631-651-9354
Practice Address - Street 1:1 BEACH HILL DR
Practice Address - Street 2:
Practice Address - City:FORT SALONGA
Practice Address - State:NY
Practice Address - Zip Code:11768-1423
Practice Address - Country:US
Practice Address - Phone:631-896-3240
Practice Address - Fax:631-651-9354
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-12
Last Update Date:2009-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY881114133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered