Healthcare Provider Details

I. General information

NPI: 1174996151
Provider Name (Legal Business Name): SUSAN REESE MS RDN CNSC CD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/12/2015
Last Update Date: 11/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2147 E PINNACLE TERRACE WAY APT 103
SALT LAKE CITY UT
84121-5062
US

IV. Provider business mailing address

PO BOX 711913
SALT LAKE CITY UT
84171-1913
US

V. Phone/Fax

Practice location:
  • Phone: 801-201-1850
  • Fax:
Mailing address:
  • Phone: 801-201-1850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number8066413-4901
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: