Healthcare Provider Details

I. General information

NPI: 1154124337
Provider Name (Legal Business Name): MONIQUE M MCMILLAN NUTRITIONISTS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2025
Last Update Date: 04/08/2025
Certification Date: 04/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1303 DR MARTIN L KING JR AVE
MOBILE AL
36603-5341
US

IV. Provider business mailing address

13311 AUGUST DR
MOBILE AL
36695-8595
US

V. Phone/Fax

Practice location:
  • Phone: 251-432-4117
  • Fax: 251-436-7765
Mailing address:
  • Phone: 251-382-8122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number5065
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: