Provider Demographics
NPI:1750864096
Name:GALLANT, MONIQUE YVONNE (RDN, LD)
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:YVONNE
Last Name:GALLANT
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2411 BAKER RIDGE ROAD
Mailing Address - Street 2:
Mailing Address - City:WILLISBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40078
Mailing Address - Country:US
Mailing Address - Phone:603-733-6142
Mailing Address - Fax:
Practice Address - Street 1:800 ZORN AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40206-1433
Practice Address - Country:US
Practice Address - Phone:603-733-6142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-12
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY243798133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered