Healthcare Provider Details

I. General information

NPI: 1508442500
Provider Name (Legal Business Name): AIMEE J MCDONOUGH MS, RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2021
Last Update Date: 03/20/2021
Certification Date: 03/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4370 W MAIN ST # 41
DOTHAN AL
36305-1056
US

IV. Provider business mailing address

2202 MAPLEBROOK LN
DOTHAN AL
36301-4126
US

V. Phone/Fax

Practice location:
  • Phone: 334-944-7095
  • Fax:
Mailing address:
  • Phone: 334-406-1623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2952
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: