Provider Demographics
NPI:1942801154
Name:BURR, STEPHANIE LYNN (CDN,CNS)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LYNN
Last Name:BURR
Suffix:
Gender:F
Credentials:CDN,CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 VAN ORMAN ST
Mailing Address - Street 2:
Mailing Address - City:OAKVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06779-1922
Mailing Address - Country:US
Mailing Address - Phone:860-417-8398
Mailing Address - Fax:
Practice Address - Street 1:57 VAN ORMAN ST
Practice Address - Street 2:
Practice Address - City:OAKVILLE
Practice Address - State:CT
Practice Address - Zip Code:06779-1922
Practice Address - Country:US
Practice Address - Phone:860-417-8398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001917133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001917OtherCDN