Healthcare Provider Details

I. General information

NPI: 1518225051
Provider Name (Legal Business Name): SUSAN MOFFATT AGNES RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2012
Last Update Date: 05/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 KRIPES RD
EAST GRANBY CT
06026-9669
US

IV. Provider business mailing address

PO BOX 152
SIMSBURY CT
06070-0152
US

V. Phone/Fax

Practice location:
  • Phone: 860-413-3883
  • Fax: 860-413-3884
Mailing address:
  • Phone: 860-413-3883
  • Fax: 860-413-3884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number709473
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: