Healthcare Provider Details

I. General information

NPI: 1144354176
Provider Name (Legal Business Name): SUSAN LEE DEMORLIS RD, LD, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4050 COON RAPIDS BLVD NW MERCY HOSPITAL -- NUTRITION SERVICES
COON RAPIDS MN
55433-2522
US

IV. Provider business mailing address

14235 BOWERS DR NW
RAMSEY MN
55303-7211
US

V. Phone/Fax

Practice location:
  • Phone: 763-236-8704
  • Fax:
Mailing address:
  • Phone: 763-421-8159
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1072
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: