Healthcare Provider Details

I. General information

NPI: 1124236385
Provider Name (Legal Business Name): SUZANNE CAROL ICKES R.D., LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2007
Last Update Date: 09/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2545 SCHOENERSVILLE RD LEHIGHVALLEY HOSPITAL -CLINICAL NUTRITION
BETHLEHEM PA
18017-7300
US

IV. Provider business mailing address

45 WARWICK ST SUITE 100
BETHLEHEM PA
18018-2431
US

V. Phone/Fax

Practice location:
  • Phone: 484-788-1255
  • Fax:
Mailing address:
  • Phone: 484-788-1255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDN001762
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: