Provider Demographics
NPI:1336277862
Name:HALEY, SUSAN SHERIDAN (RD, LDN)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:SHERIDAN
Last Name:HALEY
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 1:3250 ZEMKE AVE BLDG 1078
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33621-5023
Mailing Address - Country:US
Mailing Address - Phone:813-828-4739
Mailing Address - Fax:
Practice Address - Street 1:3250 ZEMKE AVE BLDG 1078
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33621-5023
Practice Address - Country:US
Practice Address - Phone:813-828-4739
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND1300133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered