Basic Information
| Provider Information | |||||||||
| NPI: | 1245205988 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SUDERMAN | ||||||||
| FirstName: | DANIELLE | ||||||||
| MiddleName: | |||||||||
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| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2101 N WALDRON ST | ||||||||
| Address2: | |||||||||
| City: | HUTCHINSON | ||||||||
| State: | KS | ||||||||
| PostalCode: | 675021131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6206692500 | ||||||||
| FaxNumber: | 6206692597 | ||||||||
| Practice Location | |||||||||
| Address1: | 2101 N WALDRON ST | ||||||||
| Address2: | |||||||||
| City: | HUTCHINSON | ||||||||
| State: | KS | ||||||||
| PostalCode: | 675021131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6206692500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2006 | ||||||||
| LastUpdateDate: | 08/24/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 000328 | KS | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 100087920C | 05 | KS | MEDICAID |