Provider Demographics
NPI:1568799633
Name:BRENNER, STEPHANIE K (MS, RD, LD/N)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:K
Last Name:BRENNER
Suffix:
Gender:F
Credentials:MS, RD, LD/N
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:K
Other - Last Name:RADOW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LD/N
Mailing Address - Street 1:435 PALM CREST LN
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-7105
Mailing Address - Country:US
Mailing Address - Phone:407-489-8534
Mailing Address - Fax:407-549-7207
Practice Address - Street 1:620 N WYMORE RD
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-4268
Practice Address - Country:US
Practice Address - Phone:407-647-4740
Practice Address - Fax:407-647-6415
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-11
Last Update Date:2009-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND 5088133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered