Healthcare Provider Details

I. General information

NPI: 1497192249
Provider Name (Legal Business Name): SUZANNE LYNN FORSBERG RD, LD, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2013
Last Update Date: 06/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14500 S 4240 RD
CLAREMORE OK
74017-1127
US

IV. Provider business mailing address

14500 S 4240 RD
CLAREMORE OK
74017-1127
US

V. Phone/Fax

Practice location:
  • Phone: 918-352-5201
  • Fax:
Mailing address:
  • Phone: 918-352-5201
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number818967
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License NumberLD990
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number09720118
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: