Provider Demographics
NPI:1710641469
Name:O'CONNELL, ETHAN (RD)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:O'CONNELL
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12304 WILLOW WOODS DR
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22407-6659
Mailing Address - Country:US
Mailing Address - Phone:540-718-8961
Mailing Address - Fax:
Practice Address - Street 1:12304 WILLOW WOODS DR
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22407-6659
Practice Address - Country:US
Practice Address - Phone:540-718-8961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-28
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered