Healthcare Provider Details

I. General information

NPI: 1639260730
Provider Name (Legal Business Name): SHARON ELIZABETH BRANDL RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 09/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 BATTLEFIELD BLVD N
CHESAPEAKE VA
23320-0305
US

IV. Provider business mailing address

1153 BIRKS LN
VIRGINIA BEACH VA
23464-5826
US

V. Phone/Fax

Practice location:
  • Phone: 757-408-8345
  • Fax: 757-382-7572
Mailing address:
  • Phone: 757-408-8345
  • Fax: 757-382-7572

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number805568
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License NumberL001905
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: