Provider Demographics
NPI:1154547115
Name:WARREN, SUSAN ROBERTA (MS,RD,LN,CDE)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:ROBERTA
Last Name:WARREN
Suffix:
Gender:F
Credentials:MS,RD,LN,CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 1337
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87305-1337
Mailing Address - Country:US
Mailing Address - Phone:505-722-1000
Mailing Address - Fax:928-729-8045
Practice Address - Street 1:516 E. NIZHONI BLVD.
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5748
Practice Address - Country:US
Practice Address - Phone:505-722-1000
Practice Address - Fax:928-729-8045
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM149133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM149OtherLN