Provider Demographics
NPI:1699709147
Name:IADANZA, SUSANNE M (RD)
Entity type:Individual
Prefix:
First Name:SUSANNE
Middle Name:M
Last Name:IADANZA
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 115
Mailing Address - Street 2:MEDICAL STAFF SERVICES/CREDENTIALING
Mailing Address - City:SACATON
Mailing Address - State:AZ
Mailing Address - Zip Code:85247-0115
Mailing Address - Country:US
Mailing Address - Phone:602-528-1340
Mailing Address - Fax:602-528-1296
Practice Address - Street 1:483 W. SEED FARM RD.
Practice Address - Street 2:
Practice Address - City:SACATON
Practice Address - State:AZ
Practice Address - Zip Code:85247
Practice Address - Country:US
Practice Address - Phone:602-528-1340
Practice Address - Fax:602-528-1296
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL894385133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
$$$$$$$$$OtherSSN