Healthcare Provider Details

I. General information

NPI: 1295762425
Provider Name (Legal Business Name): SUSAN M LISTER R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 07/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ONE MEDICAL CENTER DRIVE
CLARKSBURG WV
26301
US

IV. Provider business mailing address

RR 2 BOX 39E
SALEM WV
26426-9403
US

V. Phone/Fax

Practice location:
  • Phone: 304-623-3461
  • Fax: 304-626-7008
Mailing address:
  • Phone: 304-623-3461
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number17
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: