Provider Demographics
NPI:1962984559
Name:BRUMLEY, SUSAN L (RD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:BRUMLEY
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 1:4214 N 38TH ST UNIT C
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-4839
Mailing Address - Country:US
Mailing Address - Phone:602-736-7397
Mailing Address - Fax:
Practice Address - Street 1:5090 N 40TH ST STE 250
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018
Practice Address - Country:US
Practice Address - Phone:602-258-3354
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-30
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
439298133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
439298OtherCDR