Healthcare Provider Details

I. General information

NPI: 1336256320
Provider Name (Legal Business Name): KIM JEANETTE MCCONNELL RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NUTRITION AND FOOD SERVICE PP VAMC
PERRY POINT MD
21902
US

IV. Provider business mailing address

NUTRITION AND FOOD SERVICE PP VAMC
PERRY POINT MD
21902
US

V. Phone/Fax

Practice location:
  • Phone: 410-642-2411
  • Fax:
Mailing address:
  • Phone: 410-642-2411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberB00216
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: