Provider Demographics
NPI:1093094575
Name:BRINE, ELIZABETH ANN (MMSC, RD, CD)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:ANN
Last Name:BRINE
Suffix:
Gender:F
Credentials:MMSC, RD, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3237 W COUNTY ROAD 875 S
Mailing Address - Street 2:
Mailing Address - City:REELSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46171-9477
Mailing Address - Country:US
Mailing Address - Phone:317-508-3136
Mailing Address - Fax:765-672-4685
Practice Address - Street 1:3237 W COUNTY ROAD 875 S
Practice Address - Street 2:
Practice Address - City:REELSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46171-9477
Practice Address - Country:US
Practice Address - Phone:317-508-3136
Practice Address - Fax:765-672-4685
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-15
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37000065A133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric