=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255590360
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN AUSTIN DOUGLAS MS, RD, LD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2008
-----------------------------------------------------
Last Update Date | 10/02/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 295 GERMANTOWN BEND CV
-----------------------------------------------------
City | CORDOVA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38018-7238
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-759-9337
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 295 GERMANTOWN BEND CV
-----------------------------------------------------
City | CORDOVA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38018-7238
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-759-9337
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number | LDN0000001941
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number | 78
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------