Provider Demographics
NPI:1861563579
Name:EDGERLY, SUSAN MARIE (RD, CD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:EDGERLY
Suffix:
Gender:F
Credentials:RD, CD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:MARIE
Other - Last Name:HOLLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, CD
Mailing Address - Street 1:PO BOX 842151
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-2151
Mailing Address - Country:US
Mailing Address - Phone:509-458-5800
Mailing Address - Fax:509-473-4916
Practice Address - Street 1:800 W 5TH AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99210-0248
Practice Address - Country:US
Practice Address - Phone:509-473-2272
Practice Address - Fax:509-473-4916
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00001556133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8496721Medicaid
WAG8868704Medicare PIN
WAG8868705Medicare PIN
G8880316Medicare PIN
WA8496721Medicaid