Basic Information
| Provider Information | |||||||||
| NPI: | 1013996909 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REARDON | ||||||||
| FirstName: | LORRAINE | ||||||||
| MiddleName: | DAWN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RD CDN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21 GRAND STREET | ||||||||
| Address2: | |||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605507500 | ||||||||
| FaxNumber: | 8605507501 | ||||||||
| Practice Location | |||||||||
| Address1: | 21 GRAND STREET | ||||||||
| Address2: | |||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605507500 | ||||||||
| FaxNumber: | 8605507501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2006 | ||||||||
| LastUpdateDate: | 11/26/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | CT | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 004236007 | 05 | CT | MEDICAID | 000557 | 01 | CT | DIETITIAN NUTRITIONIST | OTHER |