Provider Demographics
NPI:1124236385
Name:ICKES, SUZANNE CAROL (RD, LDN)
Entity type:Individual
Prefix:MRS
First Name:SUZANNE
Middle Name:CAROL
Last Name:ICKES
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 WARWICK ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18018-2431
Mailing Address - Country:US
Mailing Address - Phone:484-788-1255
Mailing Address - Fax:
Practice Address - Street 1:2545 SCHOENERSVILLE RD
Practice Address - Street 2:LEHIGHVALLEY HOSPITAL -CLINICAL NUTRITION
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18017-7300
Practice Address - Country:US
Practice Address - Phone:484-788-1255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-20
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN001762133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2630546000OtherINDEPENDENCE BLUE CROSS
PA2630546000OtherKEYSTONE HEALTH EAST
PA001793520OtherHIGHMARK BLUE SHIELD FOR FEDERAL EMPLOYEES
PA2624640OtherAETNA US HEALTHCARE
PA2630546000OtherPERSONALCHOICE/BLUECHOICE
PA055154OtherMEDICARE PROVIDER NUMBER
PA001793520000OtherAMERIHEALTH