MEDICARE: MRS. SUZANNE BORRER WHITEHEAD DIETITIAN

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	133V00000X	Registered Dietitian	LD206	OK

General Provider Information

NPI Number	:	1538296173
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SUZANNE BORRER WHITEHEAD DIETITIAN

Provider Business Mailing Address
First Line	:	1515 LAWRIE TATUM RD
Second Line	:
City	:	LAWTON
State	:	OK
Zip	:	73507-3099
Country	:	US
Telephone Number	:	580-353-0350
Fax Number	:	580-353-2914

Provider Business Practice Location Address
First Line	:	1515 LAWRIE TATUM RD
Second Line	:
City	:	LAWTON
State	:	OK
Zip	:	73507-3099
Country	:	US
Telephone Number	:	580-353-0350
Fax Number	:	580-353-2914

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

Provider Enumeration Date	:	02/28/2007
Last Update Date	:	07/08/2007

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