Healthcare Provider Details

I. General information

NPI: 1699816504
Provider Name (Legal Business Name): SUSAN PEACOCK M.S.,R.D.,LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 06/18/2022
Certification Date: 06/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2240 W WOOLBRIGHT RD STE 305
BOYNTON BEACH FL
33426-6363
US

IV. Provider business mailing address

100 WATERWAY DR S APT 203
LANTANA FL
33462-1827
US

V. Phone/Fax

Practice location:
  • Phone: 561-758-1734
  • Fax: 561-540-5186
Mailing address:
  • Phone: 561-758-1734
  • Fax: 561-540-5186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberND3521
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: