Provider Demographics
NPI:1467963520
Name:MADOLE, BRENDA (RDN, LDN)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:
Last Name:MADOLE
Suffix:
Gender:F
Credentials:RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 MARE POND PL
Mailing Address - Street 2:
Mailing Address - City:HAMPSTEAD
Mailing Address - State:NC
Mailing Address - Zip Code:28443-2005
Mailing Address - Country:US
Mailing Address - Phone:714-713-2831
Mailing Address - Fax:
Practice Address - Street 1:220 MARE POND PL
Practice Address - Street 2:
Practice Address - City:HAMPSTEAD
Practice Address - State:NC
Practice Address - Zip Code:28443-2005
Practice Address - Country:US
Practice Address - Phone:714-713-2831
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-17
Last Update Date:2017-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA849281133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered