Provider Demographics
NPI:1861590333
Name:TALBERT, SUE MCKENZIE (RD CDE LDN)
Entity type:Individual
Prefix:MRS
First Name:SUE
Middle Name:MCKENZIE
Last Name:TALBERT
Suffix:
Gender:F
Credentials:RD CDE LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 COLLEGE STREET
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28540
Mailing Address - Country:US
Mailing Address - Phone:910-347-2154
Mailing Address - Fax:910-347-2789
Practice Address - Street 1:1450 LEONARD ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-5515
Practice Address - Country:US
Practice Address - Phone:616-774-8789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL001793133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC710000239OtherMEDICARE RAILROAD CARRIER
NC710000239OtherMEDICARE RAILROAD CARRIER
P52301Medicare UPIN