Healthcare Provider Details

I. General information

NPI: 1265181861
Provider Name (Legal Business Name): BRITTANY ROMAN-GREEN NUTRITION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2022
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 BAYWOOD DR FL 2
PETALUMA CA
94954-5510
US

IV. Provider business mailing address

91 WHEATON AVE
FISHKILL NY
12524-1110
US

V. Phone/Fax

Practice location:
  • Phone: 707-285-7675
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: JOSEPH ROGERS
Title or Position: CEO
Credential:
Phone: 845-416-5074