=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578321493
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | COREY BRADY MDN, RDN, LD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2024
-----------------------------------------------------
Last Update Date | 06/23/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 721 RAYMOND DR UNIT 107
-----------------------------------------------------
City | ETNA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43062-3006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-963-2872
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 721 RAYMOND DR UNIT 107
-----------------------------------------------------
City | ETNA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43062-3006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-963-2872
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number | 10371
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------