Provider Demographics
NPI:1457619785
Name:REARDON, JULIANNA FAULKNER (RD)
Entity type:Individual
Prefix:
First Name:JULIANNA
Middle Name:FAULKNER
Last Name:REARDON
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 1:1015 BOWLES AVE
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-2394
Mailing Address - Country:US
Mailing Address - Phone:636-496-3330
Mailing Address - Fax:636-496-4985
Practice Address - Street 1:1015 BOWLES AVE
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-2394
Practice Address - Country:US
Practice Address - Phone:636-496-3330
Practice Address - Fax:636-496-4985
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-24
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO200126153133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered