Provider Demographics
NPI:1598509101
Name:BISSONNETTE, BRENNAN (RDN)
Entity type:Individual
Prefix:MISS
First Name:BRENNAN
Middle Name:
Last Name:BISSONNETTE
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 S BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:NYACK
Mailing Address - State:NY
Mailing Address - Zip Code:10960-4115
Mailing Address - Country:US
Mailing Address - Phone:401-787-5924
Mailing Address - Fax:
Practice Address - Street 1:1104 HULL ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21230-5237
Practice Address - Country:US
Practice Address - Phone:443-880-0843
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-20
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX6712133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered