Provider Demographics
NPI:1043414766
Name:STRUB, BRANDY
Entity Type:Individual
Prefix:
First Name:BRANDY
Middle Name:
Last Name:STRUB
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1216 WOODSIDE LN
Mailing Address - Street 2:
Mailing Address - City:WAUKON
Mailing Address - State:IA
Mailing Address - Zip Code:52172-7650
Mailing Address - Country:US
Mailing Address - Phone:563-422-3811
Mailing Address - Fax:563-422-9754
Practice Address - Street 1:112 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:WEST UNION
Practice Address - State:IA
Practice Address - Zip Code:52175-1022
Practice Address - Country:US
Practice Address - Phone:563-422-3811
Practice Address - Fax:563-422-9754
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001771133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered