Basic Information
| Provider Information | |||||||||
| NPI: | 1215566088 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRYANT | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | JEAN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LDN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRYANT | ||||||||
| OtherFirstName: | SANDRA | ||||||||
| OtherMiddleName: | JEAN | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LDN | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 25 HALL RD | ||||||||
| Address2: | |||||||||
| City: | LONDONDERRY | ||||||||
| State: | NH | ||||||||
| PostalCode: | 030532306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034903244 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 145 HOLLIS ST | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 031011235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036269500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2020 | ||||||||
| LastUpdateDate: | 04/03/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133N00000X | LDN00354 | RI | Y | 193400000X SINGLE SPECIALTY GROUP | Dietary & Nutritional Service Providers | Nutritionist |
ID Information
| ID | Type | State | Issuer | Description | LDN00354 | 05 | RI | MEDICAID |