Healthcare Provider Details

I. General information

NPI: 1205308012
Provider Name (Legal Business Name): KOREN H. BRADSHAW MS, CLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2018
Last Update Date: 12/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32 ERMINE ST
FAIRFIELD CT
06824-5109
US

IV. Provider business mailing address

32 ERMINE ST
FAIRFIELD CT
06824-5109
US

V. Phone/Fax

Practice location:
  • Phone: 617-827-5223
  • Fax:
Mailing address:
  • Phone: 617-827-5223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: