Healthcare Provider Details

I. General information

NPI: 1497151732
Provider Name (Legal Business Name): SUSAN BRENNAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2014
Last Update Date: 11/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 VINE ST
MIDDLETOWN PA
17057-3565
US

IV. Provider business mailing address

500 UNIVERSITY DR
HERSHEY PA
17033-2360
US

V. Phone/Fax

Practice location:
  • Phone: 717-531-7260
  • Fax: 717-531-0806
Mailing address:
  • Phone: 800-243-1455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDN004311
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: