Healthcare Provider Details

I. General information

NPI: 1023221660
Provider Name (Legal Business Name): SUSAN K. VANDERTIE RD CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2323 N LAKE DR
MILWAUKEE WI
53211-4508
US

IV. Provider business mailing address

1010 N 122ND ST
WAUWATOSA WI
53226-3312
US

V. Phone/Fax

Practice location:
  • Phone: 414-291-1143
  • Fax: 414-291-1999
Mailing address:
  • Phone: 414-259-1935
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: