Provider Demographics
NPI:1336310200
Name:MCCONNELL, KARA
Entity Type:Individual
Prefix:MS
First Name:KARA
Middle Name:
Last Name:MCCONNELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 NEWARK POMPTON TPKE
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07457
Mailing Address - Country:US
Mailing Address - Phone:973-616-4555
Mailing Address - Fax:973-616-3430
Practice Address - Street 1:18 NEWARK POMPTON TPKE
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:NJ
Practice Address - Zip Code:07457
Practice Address - Country:US
Practice Address - Phone:973-616-4555
Practice Address - Fax:973-616-3430
Is Sole Proprietor?:No
Enumeration Date:2008-03-18
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
00857936133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
857936OtherCOMMISSION ON DIATETIC RE