Provider Demographics
NPI:1538446596
Name:MACDONALD, SUZANNE NMI
Entity type:Individual
Prefix:MRS
First Name:SUZANNE
Middle Name:NMI
Last Name:MACDONALD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SUZANNE
Other - Middle Name:NMI
Other - Last Name:MACDONALD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RD
Mailing Address - Street 1:1813 FLINT PL
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-2541
Mailing Address - Country:US
Mailing Address - Phone:707-971-9021
Mailing Address - Fax:
Practice Address - Street 1:1220 N DUTTON AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-4608
Practice Address - Country:US
Practice Address - Phone:707-971-9021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-04
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered