Provider Demographics
NPI:1356938773
Name:MCBURNETT, STEPHANIE ANN (RDN)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANN
Last Name:MCBURNETT
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:ANN
Other - Last Name:MENZEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16 CANOPUS AVE
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-2825
Mailing Address - Country:US
Mailing Address - Phone:240-475-7920
Mailing Address - Fax:
Practice Address - Street 1:16 CANOPUS AVE
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-2825
Practice Address - Country:US
Practice Address - Phone:240-475-7920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-31
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT86096327133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered