Provider Demographics
NPI:1730615584
Name:WRIGHT, SUSAN (RD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:WRIGHT
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1965 S FREMONT AVE STE 220
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-2283
Mailing Address - Country:US
Mailing Address - Phone:417-820-7731
Mailing Address - Fax:
Practice Address - Street 1:1965 S FREMONT AVE STE 220
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2283
Practice Address - Country:US
Practice Address - Phone:417-820-7731
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011031072133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOPENDINGMedicaid
MOPENDINGMedicare PIN