Provider Demographics
NPI:1427231182
Name:PITTMAN, SUSAN (RD,LD,CDE)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:PITTMAN
Suffix:
Gender:F
Credentials:RD,LD,CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1102 W 32ND ST
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-3503
Mailing Address - Country:US
Mailing Address - Phone:417-347-5833
Mailing Address - Fax:417-347-5821
Practice Address - Street 1:1102 W 32ND ST
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-3503
Practice Address - Country:US
Practice Address - Phone:417-347-5833
Practice Address - Fax:417-347-5821
Is Sole Proprietor?:No
Enumeration Date:2007-12-17
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002023547133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered