MEDICARE: ELIZABETH BRADLEY RD

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

General Provider Information

NPI Number	:	1316725369
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH BRADLEY RD

Provider Business Mailing Address
First Line	:	68 SAINT MARKS PL APT 3
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11217-1945
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	68 SAINT MARKS PL APT 3
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11217-1945
Country	:	US
Telephone Number	:	646-402-5272
Fax Number	:

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

Provider Enumeration Date	:	09/20/2023
Last Update Date	:	09/20/2023

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Directions to “ ELIZABETH BRADLEY RD” Practice Location

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