Provider Demographics
NPI:1356027882
Name:SOUTHERLAND, BRANDI (RD, LD)
Entity type:Individual
Prefix:
First Name:BRANDI
Middle Name:
Last Name:SOUTHERLAND
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5720 WINDSOR WAY
Mailing Address - Street 2:
Mailing Address - City:EASTMAN
Mailing Address - State:GA
Mailing Address - Zip Code:31023-5560
Mailing Address - Country:US
Mailing Address - Phone:229-212-0186
Mailing Address - Fax:
Practice Address - Street 1:5720 WINDSOR WAY
Practice Address - Street 2:
Practice Address - City:EASTMAN
Practice Address - State:GA
Practice Address - Zip Code:31023-5560
Practice Address - Country:US
Practice Address - Phone:229-212-0186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-27
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD003573133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty