Provider Demographics
NPI:1982614947
Name:QUIMBY, SUSAN A (RD,LD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:A
Last Name:QUIMBY
Suffix:
Gender:F
Credentials:RD,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 STEVENS AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-2626
Mailing Address - Country:US
Mailing Address - Phone:207-772-6279
Mailing Address - Fax:207-347-4281
Practice Address - Street 1:805 STEVENS AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-2626
Practice Address - Country:US
Practice Address - Phone:207-772-6279
Practice Address - Fax:207-347-4281
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MED121133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME3534992OtherAETNA
ME11240707OtherCAQH
ME022185OtherANTHEM
ME3534992OtherAETNA