MEDICARE: SUSAN REESE MS RDN CNSC CD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133VN1004X	Pediatric Nutrition Registered Dietitian	8066413-4901	UT

General Provider Information

NPI Number	:	1174996151
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN REESE MS RDN CNSC CD

Provider Business Mailing Address
First Line	:	PO BOX 711913
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84171-1913
Country	:	US
Telephone Number	:	801-201-1850
Fax Number	:

Provider Business Practice Location Address
First Line	:	2147 E PINNACLE TERRACE WAY
Second Line	:	APT 103
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121-5062
Country	:	US
Telephone Number	:	801-201-1850
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/12/2015
Last Update Date	:	11/12/2015

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