Basic Information
| Provider Information | |||||||||
| NPI: | 1801916408 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WIKEN | ||||||||
| FirstName: | SUZANNE | ||||||||
| MiddleName: | M | ||||||||
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| NameSuffix: | |||||||||
| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1231 | ||||||||
| Address2: | |||||||||
| City: | HAVRE | ||||||||
| State: | MT | ||||||||
| PostalCode: | 595011231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062652211 | ||||||||
| FaxNumber: | 4062651651 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 13TH ST | ||||||||
| Address2: | |||||||||
| City: | HAVRE | ||||||||
| State: | MT | ||||||||
| PostalCode: | 595015222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062652211 | ||||||||
| FaxNumber: | 4062651651 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2007 | ||||||||
| LastUpdateDate: | 02/14/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 268 | MT | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 0000298408 | 01 | MT | BLUE CROSS BLUE SHIELD | OTHER | 1801916408 | 05 | MT | MEDICAID |