Provider Demographics
NPI:1093811838
Name:MOONEY, CONSTANCE DESMOND (RD)
Entity Type:Individual
Prefix:MS
First Name:CONSTANCE
Middle Name:DESMOND
Last Name:MOONEY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:MS
Other - First Name:CONSTANCE
Other - Middle Name:
Other - Last Name:DESMOND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:874 EAST 2ND STREET
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02127
Mailing Address - Country:US
Mailing Address - Phone:617-268-9204
Mailing Address - Fax:
Practice Address - Street 1:1400 VFW PARKWAY
Practice Address - Street 2:
Practice Address - City:WEST ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02132-4927
Practice Address - Country:US
Practice Address - Phone:617-323-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1684133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered