Provider Demographics
NPI:1720103856
Name:BRADSHER, KRISTINE BENNETT (RD)
Entity Type:Individual
Prefix:MRS
First Name:KRISTINE
Middle Name:BENNETT
Last Name:BRADSHER
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 1:21408 LAYTONSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:LAYTONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20882-1622
Mailing Address - Country:US
Mailing Address - Phone:301-947-1775
Mailing Address - Fax:
Practice Address - Street 1:21408 LAYTONSVILLE RD
Practice Address - Street 2:
Practice Address - City:LAYTONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20882-1622
Practice Address - Country:US
Practice Address - Phone:301-947-1775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDI34133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered