Healthcare Provider Details

I. General information

NPI: 1851663116
Provider Name (Legal Business Name): SUSAN MORSE RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2012
Last Update Date: 02/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3930 SAVANNAH LN
SPRINGDALE AR
72762-7994
US

IV. Provider business mailing address

3930 SAVANNAH LN
SPRINGDALE AR
72762-7994
US

V. Phone/Fax

Practice location:
  • Phone: 479-530-5717
  • Fax: 479-756-8810
Mailing address:
  • Phone: 479-530-5717
  • Fax: 479-756-8810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number782
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: