Provider Demographics
NPI:1215566088
Name:BRYANT, SANDRA JEAN (LDN)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:JEAN
Last Name:BRYANT
Suffix:
Gender:F
Credentials:LDN
Other - Prefix:MRS
Other - First Name:SANDRA
Other - Middle Name:JEAN
Other - Last Name:BRYANT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LDN
Mailing Address - Street 1:25 HALL RD
Mailing Address - Street 2:
Mailing Address - City:LONDONDERRY
Mailing Address - State:NH
Mailing Address - Zip Code:03053-2306
Mailing Address - Country:US
Mailing Address - Phone:603-490-3244
Mailing Address - Fax:
Practice Address - Street 1:145 HOLLIS ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03101-1235
Practice Address - Country:US
Practice Address - Phone:603-626-9500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-03
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILDN00354133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RILDN00354Medicaid