Provider Demographics
NPI:1063959922
Name:BRENNA JOY DIETITIAN, LLC
Entity type:Organization
Organization Name:BRENNA JOY DIETITIAN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRENNA
Authorized Official - Middle Name:J
Authorized Official - Last Name:SWANSON
Authorized Official - Suffix:
Authorized Official - Credentials:RDN, LRD, CDE
Authorized Official - Phone:701-331-9334
Mailing Address - Street 1:10282 61ST ST NE
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:ND
Mailing Address - Zip Code:58345-9260
Mailing Address - Country:US
Mailing Address - Phone:701-331-9334
Mailing Address - Fax:
Practice Address - Street 1:210 HIGHWAY 2 W STE 10
Practice Address - Street 2:
Practice Address - City:DEVILS LAKE
Practice Address - State:ND
Practice Address - Zip Code:58301-2913
Practice Address - Country:US
Practice Address - Phone:701-331-9334
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-30
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND628133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty