Basic Information
| Provider Information | |||||||||
| NPI: | 1669975801 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OBRIEN | ||||||||
| FirstName: | RANDI | ||||||||
| MiddleName: | Y | ||||||||
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| Credential: | RDN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 180 THIMBLE ISLAND RD | ||||||||
| Address2: | |||||||||
| City: | BRANFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064055727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033763957 | ||||||||
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| Practice Location | |||||||||
| Address1: | 800 BOSTON POST RD FL 1 | ||||||||
| Address2: | |||||||||
| City: | GUILFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064372747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037770304 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2018 | ||||||||
| LastUpdateDate: | 03/14/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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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 | 636583 | 01 | RDN REGISTRATION NUMBER | OTHER |