Individual
ALICIA D SUSILLA
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
BS
Contact information
Practice address
600 BROADWAY ST, LONGVIEW, WA 98632-3256
(360) 414-2200
(360) 414-2210
Mailing address
PO BOX 249, LONGVIEW, WA 98632-7154
Taxonomy
Speciality
Code
Description
License number
State
133V00000X
Registered Dietitian
Primary
DI00001601
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
022955
—
OR
05
—
8416349
—
WA
Enumeration date
09/07/2005
Last updated
07/09/2007
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