Provider Demographics
NPI:1538296173
Name:WHITEHEAD, SUZANNE BORRER (DIETITIAN)
Entity type:Individual
Prefix:MRS
First Name:SUZANNE
Middle Name:BORRER
Last Name:WHITEHEAD
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 1:1515 LAWRIE TATUM RD
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73507-3099
Mailing Address - Country:US
Mailing Address - Phone:580-353-0350
Mailing Address - Fax:580-353-2914
Practice Address - Street 1:1515 LAWRIE TATUM RD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73507-3099
Practice Address - Country:US
Practice Address - Phone:580-353-0350
Practice Address - Fax:580-353-2914
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKLD206133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered