Provider Demographics
NPI:1407306871
Name:RICHARDSON, BREANNA NICOLE (RD)
Entity Type:Individual
Prefix:MRS
First Name:BREANNA
Middle Name:NICOLE
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:BREANNA
Other - Middle Name:NICOLE
Other - Last Name:WHITTAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:2620 E BARNETT RD
Mailing Address - Street 2:#H
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8344
Mailing Address - Country:US
Mailing Address - Phone:541-789-4281
Mailing Address - Fax:541-789-2558
Practice Address - Street 1:500 SW RAMSEY AVE
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5554
Practice Address - Country:US
Practice Address - Phone:541-472-7120
Practice Address - Fax:541-472-7123
Is Sole Proprietor?:No
Enumeration Date:2016-10-10
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLD-D-10159157133V00000X, 133VN1004X, 133VN1005X, 133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
No133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic