Basic Information
| Provider Information | |||||||||
| NPI: | 1942451893 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ERICKSON | ||||||||
| FirstName: | BREANN | ||||||||
| MiddleName: | SARA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FARNSWORTH | ||||||||
| OtherFirstName: | BREANN | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 123 WIKLUND AVE | ||||||||
| Address2: | |||||||||
| City: | STRATFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06614 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 208 VALLEY ROAD | ||||||||
| Address2: | |||||||||
| City: | NEW CANAAN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2038695515 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2008 | ||||||||
| LastUpdateDate: | 02/27/2019 | ||||||||
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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 | N | Dietary & Nutritional Service Providers | Dietitian, Registered | 133V00000X | 00869 | CT | Y | 193400000X SINGLE SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.