Provider Demographics
NPI:1861893000
Name:KIM, SUSAN (MS, RD, CNSC)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:MS, RD, CNSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21011 STORRS ROAD
Mailing Address - Street 2:
Mailing Address - City:SACKETS HARBOR
Mailing Address - State:NY
Mailing Address - Zip Code:13685
Mailing Address - Country:US
Mailing Address - Phone:720-771-6691
Mailing Address - Fax:
Practice Address - Street 1:21011 STORRS RD
Practice Address - Street 2:
Practice Address - City:SACKETS HARBOR
Practice Address - State:NY
Practice Address - Zip Code:13685-3172
Practice Address - Country:US
Practice Address - Phone:720-771-6691
Practice Address - Fax:720-771-6691
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1105343133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered