Provider Demographics
NPI:1114795432
Name:BROADY, COURTNEY (RD, LD)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:BROADY
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1295 BANDANA BLVD W,
Mailing Address - Street 2:STE 210
Mailing Address - City:ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8001 RAVINES EDGE CT
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43235-5423
Practice Address - Country:US
Practice Address - Phone:888-364-5977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-15
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLD.10379133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered