Provider Demographics
NPI:1538554027
Name:BRANNON, LAURYN
Entity type:Individual
Prefix:
First Name:LAURYN
Middle Name:
Last Name:BRANNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:688 E MILLSAP RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4095
Mailing Address - Country:US
Mailing Address - Phone:479-463-3070
Mailing Address - Fax:479-463-3077
Practice Address - Street 1:688 E MILLSAP RD
Practice Address - Street 2:SUITE 100
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4095
Practice Address - Country:US
Practice Address - Phone:479-463-3070
Practice Address - Fax:479-463-3077
Is Sole Proprietor?:No
Enumeration Date:2015-04-01
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered