Provider Demographics
NPI:1710638945
Name:BRAINARD, STEPHANIE (RD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:BRAINARD
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 LASALLE RD
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-2322
Mailing Address - Country:US
Mailing Address - Phone:860-906-1289
Mailing Address - Fax:
Practice Address - Street 1:480 NAUBUC AVE
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-1016
Practice Address - Country:US
Practice Address - Phone:860-494-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-10
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT86291527133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered