Healthcare Provider Details

I. General information

NPI: 1215566088
Provider Name (Legal Business Name): SANDRA JEAN BRYANT LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SANDRA JEAN BRYANT LDN

II. Dates (important events)

Enumeration Date: 04/03/2020
Last Update Date: 04/03/2020
Certification Date: 04/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 HOLLIS ST
MANCHESTER NH
03101-1235
US

IV. Provider business mailing address

25 HALL RD
LONDONDERRY NH
03053-2306
US

V. Phone/Fax

Practice location:
  • Phone: 603-626-9500
  • Fax:
Mailing address:
  • Phone: 603-490-3244
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberLDN00354
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: