Healthcare Provider Details

I. General information

NPI: 1548473994
Provider Name (Legal Business Name): LANAH JO BRENNAN RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 07/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4540 AMBASSADOR CAFFERY PKWY C-240
LAFAYETTE LA
70508-6928
US

IV. Provider business mailing address

117 EMILY CIR
LAFAYETTE LA
70508-6755
US

V. Phone/Fax

Practice location:
  • Phone: 337-255-8557
  • Fax: 337-504-2421
Mailing address:
  • Phone: 337-255-8557
  • Fax: 337-504-2421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number00945087
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2156
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: