Healthcare Provider Details

I. General information

NPI: 1306249578
Provider Name (Legal Business Name): JEANNE FARRELL RD, CNSC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2014
Last Update Date: 10/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 6TH AVE S
ST PETERSBURG FL
33701-4634
US

IV. Provider business mailing address

205 TIDAL LN APT 104
BRADENTON FL
34212-4446
US

V. Phone/Fax

Practice location:
  • Phone: 727-767-8419
  • Fax:
Mailing address:
  • Phone: 727-767-8419
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License NumberND1271
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: