Provider Demographics
NPI:1205308012
Name:BRADSHAW, KOREN H (MS, CLC)
Entity type:Individual
Prefix:
First Name:KOREN
Middle Name:H
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:MS, CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 ERMINE ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06824-5109
Mailing Address - Country:US
Mailing Address - Phone:617-827-5223
Mailing Address - Fax:
Practice Address - Street 1:32 ERMINE ST
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824-5109
Practice Address - Country:US
Practice Address - Phone:617-827-5223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-19
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No174N00000XOther Service ProvidersLactation Consultant, Non-RN