Provider Demographics
NPI:1730914144
Name:HAWTHORNE, BRENDA LEE (MSRDNLDN)
Entity type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:LEE
Last Name:HAWTHORNE
Suffix:
Gender:F
Credentials:MSRDNLDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2199 COUNTY ROAD 69
Mailing Address - Street 2:
Mailing Address - City:PROCTORVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45669-8947
Mailing Address - Country:US
Mailing Address - Phone:304-544-4005
Mailing Address - Fax:304-526-8817
Practice Address - Street 1:2900 1ST AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25702-1241
Practice Address - Country:US
Practice Address - Phone:304-526-1948
Practice Address - Fax:304-526-8817
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-05
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2263133V00000X
WV169133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered