Provider Demographics
NPI:1801143193
Name:FITZGERALD, SUSAN (RD)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:
Last Name:FITZGERALD
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 1:100 MARIO CAPECCHI DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84113-1103
Mailing Address - Country:US
Mailing Address - Phone:801-662-5327
Mailing Address - Fax:801-662-5300
Practice Address - Street 1:100 MARIO CAPECCHI DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84113-1103
Practice Address - Country:US
Practice Address - Phone:801-285-1665
Practice Address - Fax:801-285-1705
Is Sole Proprietor?:No
Enumeration Date:2012-08-06
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT335531-4901133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric