Provider Demographics
NPI:1861158560
Name:BRYANT, FELICIA NICOLE (RD, LDN)
Entity type:Individual
Prefix:
First Name:FELICIA
Middle Name:NICOLE
Last Name:BRYANT
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:FELICIA
Other - Middle Name:NICOLE
Other - Last Name:STEWART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LDN
Mailing Address - Street 1:23 DOUGLAS ST
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:ME
Mailing Address - Zip Code:04252-1925
Mailing Address - Country:US
Mailing Address - Phone:207-713-6649
Mailing Address - Fax:
Practice Address - Street 1:22 BRAMHALL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3134
Practice Address - Country:US
Practice Address - Phone:207-662-0111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-17
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDI1667133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered