Provider Demographics
NPI:1104247303
Name:BROWN, NANCY (MSRD)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:BROWN
Suffix:
Gender:F
Credentials:MSRD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 HERITAGE FARM RD
Mailing Address - Street 2:
Mailing Address - City:EAST GRANBY
Mailing Address - State:CT
Mailing Address - Zip Code:06026-9677
Mailing Address - Country:US
Mailing Address - Phone:860-651-8896
Mailing Address - Fax:
Practice Address - Street 1:10 HERITAGE FARM RD
Practice Address - Street 2:
Practice Address - City:EAST GRANBY
Practice Address - State:CT
Practice Address - Zip Code:06026-9677
Practice Address - Country:US
Practice Address - Phone:860-651-8896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-16
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000574133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT270000574CT01OtherANTHEM