Healthcare Provider Details

I. General information

NPI: 1588739387
Provider Name (Legal Business Name): SUSAN G LELLIS RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 03/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3130 STATE HIGHWAY ROUTE 6
WELLFLEET MA
02667
US

IV. Provider business mailing address

PO BOX 1944
NORTH EASTHAM MA
02651
US

V. Phone/Fax

Practice location:
  • Phone: 508-349-3131
  • Fax: 508-349-1311
Mailing address:
  • Phone: 508-240-0208
  • Fax: 508-240-0499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2312
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: