Provider Demographics
NPI:1033419858
Name:BERANBAUM, RANDI KONIKOFF (MS, RD)
Entity Type:Individual
Prefix:MS
First Name:RANDI
Middle Name:KONIKOFF
Last Name:BERANBAUM
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:MS
Other - First Name:RANDI-BETH
Other - Middle Name:KONIKOFF
Other - Last Name:BERANBAUM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS, RD
Mailing Address - Street 1:5 WINGATE RD
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-4909
Mailing Address - Country:US
Mailing Address - Phone:617-470-0800
Mailing Address - Fax:
Practice Address - Street 1:5 WINGATE RD
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-4909
Practice Address - Country:US
Practice Address - Phone:617-470-0800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-26
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILDN00665133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered