Healthcare Provider Details

I. General information

NPI: 1477179281
Provider Name (Legal Business Name): BRIANNA SIDERS RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2020
Last Update Date: 02/23/2025
Certification Date: 02/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

426 INDUSTRIAL AVE STE 130
WILLISTON VT
05495-4449
US

IV. Provider business mailing address

4205 BELFORT RD STE 4015
JACKSONVILLE FL
32216-3623
US

V. Phone/Fax

Practice location:
  • Phone: 724-771-8081
  • Fax:
Mailing address:
  • Phone: 904-450-6063
  • Fax: 904-539-4091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberND12159
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: