Provider Demographics
NPI:1376175505
Name:MACOMBER, MONICA ANNE (RDN)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:ANNE
Last Name:MACOMBER
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1692
Mailing Address - Street 2:
Mailing Address - City:ALMA
Mailing Address - State:AR
Mailing Address - Zip Code:72921-1692
Mailing Address - Country:US
Mailing Address - Phone:479-461-6973
Mailing Address - Fax:
Practice Address - Street 1:810 LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901-4942
Practice Address - Country:US
Practice Address - Phone:479-461-6973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-05
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR882133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered