Provider Demographics
NPI:1770236689
Name:CONNOLLY, VANESSA LORETTA (RDN, CSR, LD)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:LORETTA
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:RDN, CSR, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 FOX CHASE DR
Mailing Address - Street 2:
Mailing Address - City:GOOSE CREEK
Mailing Address - State:SC
Mailing Address - Zip Code:29445-5413
Mailing Address - Country:US
Mailing Address - Phone:301-758-8254
Mailing Address - Fax:
Practice Address - Street 1:159 FOX CHASE DR
Practice Address - Street 2:
Practice Address - City:GOOSE CREEK
Practice Address - State:SC
Practice Address - Zip Code:29445-5413
Practice Address - Country:US
Practice Address - Phone:301-758-8254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-31
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC942920133VN1005X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered