Provider Demographics
NPI:1578695540
Name:HENNARD, BRANDI R (LD)
Entity Type:Individual
Prefix:
First Name:BRANDI
Middle Name:R
Last Name:HENNARD
Suffix:
Gender:F
Credentials:LD
Other - Prefix:
Other - First Name:BRANDI
Other - Middle Name:R
Other - Last Name:OZIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LD
Mailing Address - Street 1:4320 DIPLOMACY DRIVE
Mailing Address - Street 2:SUITE 3191
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5925
Mailing Address - Country:US
Mailing Address - Phone:907-729-4187
Mailing Address - Fax:907-729-4136
Practice Address - Street 1:4320 DIPLOMACY DRIVE
Practice Address - Street 2:SUITE 3191
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5925
Practice Address - Country:US
Practice Address - Phone:907-729-4187
Practice Address - Fax:907-729-4136
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2011-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK162133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDT6552Medicaid
AKDT6552Medicaid
AK8EB220Medicare ID - Type Unspecified