Alicia D Susilla, BS

Primary specialty

Registered DietitianTaxonomy code 133V00000X

License

DI00001601 Issued in WA

Practice address

600 Broadway St
Longview, WA 98632-3256

Phone

(360) 414-2200

Fax

(360) 414-2210

NPI assigned

Sep 7, 2005

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Bachelor of Science

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1126051200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1183939200000",
    "number": "1154315968",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 249",
            "city": "LONGVIEW",
            "state": "WA",
            "postal_code": "986327154"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "600 BROADWAY ST",
            "city": "LONGVIEW",
            "state": "WA",
            "postal_code": "986323256",
            "telephone_number": "360-414-2200",
            "fax_number": "360-414-2210"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "SUSILLA",
        "first_name": "ALICIA",
        "middle_name": "D",
        "credential": "BS",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2005-09-07",
        "last_updated": "2007-07-09",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "133V00000X",
            "taxonomy_group": "",
            "desc": "Dietitian, Registered",
            "state": "WA",
            "license": "DI00001601",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "022955",
            "state": "OR"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "8416349",
            "state": "WA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Registered Dietitian in Longview, WA
• Providers in Longview, WA by specialty
• Registered Dietitian in Washington

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 9, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.