Provider Demographics
NPI:1194952770
Name:HANSEN, SUSAN N (RD/LN,PHD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:N
Last Name:HANSEN
Suffix:
Gender:F
Credentials:RD/LN,PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 COMANCHE RD
Mailing Address - Street 2:
Mailing Address - City:FORT MEADE
Mailing Address - State:SD
Mailing Address - Zip Code:57741-1002
Mailing Address - Country:US
Mailing Address - Phone:605-469-1170
Mailing Address - Fax:
Practice Address - Street 1:113 COMANCHE RD
Practice Address - Street 2:
Practice Address - City:FORT MEADE
Practice Address - State:SD
Practice Address - Zip Code:57741-1002
Practice Address - Country:US
Practice Address - Phone:605-720-7090
Practice Address - Fax:605-720-7012
Is Sole Proprietor?:No
Enumeration Date:2009-06-22
Last Update Date:2015-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0514133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5540030Medicaid