Provider Demographics
NPI:1194050831
Name:TYLER, SUSAN CHANDLER (CBS, DIPLOMATE, CNC)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:CHANDLER
Last Name:TYLER
Suffix:
Gender:F
Credentials:CBS, DIPLOMATE, CNC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:268 NEW BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GLIDE
Mailing Address - State:OR
Mailing Address - Zip Code:97443-9609
Mailing Address - Country:US
Mailing Address - Phone:541-733-4207
Mailing Address - Fax:888-629-4949
Practice Address - Street 1:268 NEW BRIDGE RD
Practice Address - Street 2:
Practice Address - City:GLIDE
Practice Address - State:OR
Practice Address - Zip Code:97443-9609
Practice Address - Country:US
Practice Address - Phone:541-733-4207
Practice Address - Fax:888-629-4949
Is Sole Proprietor?:No
Enumeration Date:2009-10-14
Last Update Date:2009-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACERTIFICATION ONLY133NN1002X
NCCERTIFICATE 3592 DQT174400000X
NCSHC 1073174400000X
NCCERTIFICATE 3592 QBS174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education