Provider Demographics
NPI:1962530840
Name:HERAZO, DANA MARIA (RD,LD,CDE)
Entity type:Individual
Prefix:
First Name:DANA
Middle Name:MARIA
Last Name:HERAZO
Suffix:
Gender:F
Credentials:RD,LD,CDE
Other - Prefix:
Other - First Name:DANA
Other - Middle Name:MARIA
Other - Last Name:SUSZKIW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:251 N BAYOU ST
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36603-5827
Mailing Address - Country:US
Mailing Address - Phone:251-690-8847
Mailing Address - Fax:251-544-2188
Practice Address - Street 1:251 N BAYOU ST
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36603-5827
Practice Address - Country:US
Practice Address - Phone:251-690-8847
Practice Address - Fax:251-544-2188
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLD 131133V00000X
AL667852133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1063439065OtherNPI GROUP PAYEE NUMBER
AL011846OtherMEDICARE GROUP PAYEE NUMBER
AL630000013Medicaid
AL1063439065OtherNPI GROUP PAYEE NUMBER