Provider Demographics
NPI:1053457945
Name:VILLALOBOS, SUSAN MARY WIEGERT (MPH, LDN, RD)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:MARY WIEGERT
Last Name:VILLALOBOS
Suffix:
Gender:F
Credentials:MPH, LDN, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4720 S I 10 SERVICE RD W
Mailing Address - Street 2:SUITE 200
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70001-7404
Mailing Address - Country:US
Mailing Address - Phone:504-988-7542
Mailing Address - Fax:
Practice Address - Street 1:4720 S I 10 SERVICE RD W
Practice Address - Street 2:SUITE 200
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70001-7404
Practice Address - Country:US
Practice Address - Phone:504-988-7542
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1876133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4H441D867Medicare PIN