Provider Demographics
NPI:1063753739
Name:PENN, SUSAN RENEE (MS, RD, LD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:RENEE
Last Name:PENN
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3017 N BOB YOUNKIN DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-3926
Mailing Address - Country:US
Mailing Address - Phone:479-463-4333
Mailing Address - Fax:479-463-2322
Practice Address - Street 1:3017 N BOB YOUNKIN DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-3926
Practice Address - Country:US
Practice Address - Phone:479-463-4333
Practice Address - Fax:479-463-2322
Is Sole Proprietor?:No
Enumeration Date:2013-03-06
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1118133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered