Healthcare Provider Details

I. General information

NPI: 1003996786
Provider Name (Legal Business Name): SUSAN R WILLYARD DIETITIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 6TH AVE SE UNION HOSPITAL
MAYVILLE ND
58257
US

IV. Provider business mailing address

42 6TH AVE SE UNION HOSPITAL
MAYVILLE ND
58257
US

V. Phone/Fax

Practice location:
  • Phone: 701-788-3800
  • Fax: 701-788-2145
Mailing address:
  • Phone: 701-788-3800
  • Fax: 701-788-2145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number182
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: