Provider Demographics
NPI:1710125950
Name:CONNELLY, ALICE MARIEANNE (RD/LDN)
Entity Type:Individual
Prefix:MRS
First Name:ALICE
Middle Name:MARIEANNE
Last Name:CONNELLY
Suffix:
Gender:F
Credentials:RD/LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9353 STATE ROUTE 5
Mailing Address - Street 2:
Mailing Address - City:KINSMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44428-9324
Mailing Address - Country:US
Mailing Address - Phone:330-207-1066
Mailing Address - Fax:
Practice Address - Street 1:9353 STATE ROUTE 5
Practice Address - Street 2:
Practice Address - City:KINSMAN
Practice Address - State:OH
Practice Address - Zip Code:44428-9324
Practice Address - Country:US
Practice Address - Phone:330-207-1066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-27
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLD 4156133V00000X
PADN003783133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered