Provider Demographics
NPI:1760477392
Name:BRADFORD, LAURA ANN (RD)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:ANN
Last Name:BRADFORD
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:PO BOX 201
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01890-0201
Mailing Address - Country:US
Mailing Address - Phone:781-665-5760
Mailing Address - Fax:781-665-0770
Practice Address - Street 1:28 WARWICK RD
Practice Address - Street 2:
Practice Address - City:MELROSE
Practice Address - State:MA
Practice Address - Zip Code:02176-2124
Practice Address - Country:US
Practice Address - Phone:781-665-5760
Practice Address - Fax:781-665-0770
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-20
Last Update Date:2010-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1010133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
Provider Identifiers
StateIdentifier IDID TypeIssuer
BR MT0464Medicare ID - Type UnspecifiedMEDICARE PART B PROVIDER