Provider Demographics
NPI:1689221236
Name:CONWAY, TOMMIE LAVERNE (MCN, RDN, LD)
Entity Type:Individual
Prefix:
First Name:TOMMIE
Middle Name:LAVERNE
Last Name:CONWAY
Suffix:
Gender:F
Credentials:MCN, RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3851 SW GREEN OAKS BLVD STE 109
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76017-4130
Mailing Address - Country:US
Mailing Address - Phone:817-476-6332
Mailing Address - Fax:817-476-6333
Practice Address - Street 1:3851 SW GREEN OAKS BLVD STE 109
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76017-4130
Practice Address - Country:US
Practice Address - Phone:817-476-6332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-19
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX133N00000X
TXDT86066133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist