Provider Demographics
NPI:1548473994
Name:BRENNAN, LANAH JO (RD)
Entity type:Individual
Prefix:
First Name:LANAH
Middle Name:JO
Last Name:BRENNAN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 EMILY CIR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-6755
Mailing Address - Country:US
Mailing Address - Phone:337-255-8557
Mailing Address - Fax:337-504-2421
Practice Address - Street 1:4540 AMBASSADOR CAFFERY PKWY
Practice Address - Street 2:C-240
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-6928
Practice Address - Country:US
Practice Address - Phone:337-255-8557
Practice Address - Fax:337-504-2421
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2009-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL00945087133V00000X
LA2156133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LANT945087Medicare PIN