Provider Demographics
NPI:1366427023
Name:STANKORB, SUSAN MARIE (RD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:MARIE
Last Name:STANKORB
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 1:9040 JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98431-5318
Mailing Address - Country:US
Mailing Address - Phone:253-968-1773
Mailing Address - Fax:
Practice Address - Street 1:3551 ROGER BROOKE DR
Practice Address - Street 2:
Practice Address - City:FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-4504
Practice Address - Country:US
Practice Address - Phone:210-221-6305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT07554133V00000X
133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered