Provider Demographics
NPI:1700662855
Name:CARMODY, BRADEN (MS, RD, LN)
Entity type:Individual
Prefix:
First Name:BRADEN
Middle Name:
Last Name:CARMODY
Suffix:
Gender:M
Credentials:MS, RD, LN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3335 17TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201-6005
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 S BRUCE ST
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MN
Practice Address - Zip Code:56258-1934
Practice Address - Country:US
Practice Address - Phone:507-532-9661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-05
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4881133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered