Provider Demographics
NPI:1487737250
Name:LEVESQUE, SUSAN A (DIETITIAN)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:A
Last Name:LEVESQUE
Suffix:
Gender:F
Credentials:DIETITIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:557 BROOKDALE DR
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28677-4107
Mailing Address - Country:US
Mailing Address - Phone:704-873-5661
Mailing Address - Fax:704-873-4554
Practice Address - Street 1:557 BROOKDALE DR
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-4107
Practice Address - Country:US
Practice Address - Phone:704-873-5661
Practice Address - Fax:704-873-4554
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL001111133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2993870Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER