Provider Demographics
NPI:1861030371
Name:GUIDRY, MACON LOUISE CORNICK (RDN, LDN)
Entity Type:Individual
Prefix:MRS
First Name:MACON
Middle Name:LOUISE CORNICK
Last Name:GUIDRY
Suffix:
Gender:F
Credentials:RDN, LDN
Other - Prefix:MISS
Other - First Name:MACON
Other - Middle Name:LOUISE
Other - Last Name:CORNICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDN, LDN
Mailing Address - Street 1:3325 RIDGECREST CT
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-6763
Mailing Address - Country:US
Mailing Address - Phone:919-906-5740
Mailing Address - Fax:
Practice Address - Street 1:23 SUNNYBROOK RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-1855
Practice Address - Country:US
Practice Address - Phone:919-235-6439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-16
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered