Provider Demographics
NPI:1750749487
Name:MACIAS, SUZANNA (RD)
Entity type:Individual
Prefix:MS
First Name:SUZANNA
Middle Name:
Last Name:MACIAS
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 1:205 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:FORT BRAGG
Mailing Address - State:CA
Mailing Address - Zip Code:95437-5540
Mailing Address - Country:US
Mailing Address - Phone:707-964-1251
Mailing Address - Fax:707-961-3471
Practice Address - Street 1:855 SEQUOIA CIR
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437-5466
Practice Address - Country:US
Practice Address - Phone:707-964-1251
Practice Address - Fax:707-961-3471
Is Sole Proprietor?:No
Enumeration Date:2016-02-09
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86036753133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered