Provider Demographics
NPI:1588023535
Name:BRUCKMAN, RENA A (MS, RD, CD-N)
Entity type:Individual
Prefix:MS
First Name:RENA
Middle Name:A
Last Name:BRUCKMAN
Suffix:
Gender:F
Credentials:MS, RD, CD-N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 BRIAR RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06877-1034
Mailing Address - Country:US
Mailing Address - Phone:914-320-3197
Mailing Address - Fax:203-743-1110
Practice Address - Street 1:72 NORTH ST
Practice Address - Street 2:STE 205
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-5648
Practice Address - Country:US
Practice Address - Phone:914-320-3197
Practice Address - Fax:203-743-1110
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-18
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001294133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered