MEDICARE: SUSAN ASTRID BLANC NC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133NN1002X	Nutrition Education Nutritionist

General Provider Information

NPI Number	:	1013539717
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN ASTRID BLANC NC

Provider Business Mailing Address
First Line	:	2303 CAMINO RAMON # 208
Second Line	:
City	:	SAN RAMON
State	:	CA
Zip	:	94583-1392
Country	:	US
Telephone Number	:	510-610-4644
Fax Number	:	925-407-8344

Provider Business Practice Location Address
First Line	:	2303 CAMINO RAMON # 208
Second Line	:
City	:	SAN RAMON
State	:	CA
Zip	:	94583-1392
Country	:	US
Telephone Number	:	510-610-4644
Fax Number	:	925-407-8344

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/15/2020
Last Update Date	:	05/15/2020

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