MEDICARE: BRIANNA MAITLAND RD, LDN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	086290511

General Provider Information

NPI Number	:	1124810643
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIANNA MAITLAND RD, LDN

Provider Business Mailing Address
First Line	:	1212 VARSITY BLVD APT 206
Second Line	:
City	:	DEKALB
State	:	IL
Zip	:	60115-1514
Country	:	US
Telephone Number	:	734-276-9465
Fax Number	:

Provider Business Practice Location Address
First Line	:	2701 W 68TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60629-1882
Country	:	US
Telephone Number	:	734-276-9465
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/20/2025
Last Update Date	:	05/20/2025

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