MEDICARE: BRENDA SUE WARREN R.D., L.D.N.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	631668	FL

General Provider Information

NPI Number	:	1114942513
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRENDA SUE WARREN R.D., L.D.N.

Provider Business Mailing Address
First Line	:	1610 DOVER RD
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32404-7315
Country	:	US
Telephone Number	:	850-871-0736
Fax Number	:

Provider Business Practice Location Address
First Line	:	6703 W HIGHWAY 98
Second Line	:	BLDG 387
City	:	PANAMA CITY
State	:	FL
Zip	:	32407-7000
Country	:	US
Telephone Number	:	850-636-7000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/13/2006
Last Update Date	:	07/08/2007

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