MEDICARE: SUSAN L. DELAGRANGE

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	910521	IN

General Provider Information

NPI Number	:	1619209152
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUSAN L. DELAGRANGE

Provider Business Mailing Address
First Line	:	2607 BARRY KNOLL WAY
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-1942
Country	:	US
Telephone Number	:	260-433-3367
Fax Number	:	260-637-5780

Provider Business Practice Location Address
First Line	:	2607 BARRY KNOLL WAY
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-1942
Country	:	US
Telephone Number	:	260-433-3367
Fax Number	:	260-637-5780

Authorized Official
Title or Position	:	REGISTERED DIETITIAN
Name	:	SUSAN LYNN DELAGRANGE
Credential	:	MS., RD.
Telephone Number	:	260-433-3367

Provider Enumeration Date	:	02/09/2010
Last Update Date	:	03/15/2010

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