Provider Demographics
NPI:1043016066
Name:MCCONNELL, MONIQUE (RD LD)
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:
Last Name:MCCONNELL
Suffix:
Gender:
Credentials:RD LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4010 LONG CHAMP DR APT 12
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78746-1170
Mailing Address - Country:US
Mailing Address - Phone:817-528-8538
Mailing Address - Fax:
Practice Address - Street 1:1201 RIO GRANDE ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78701-1749
Practice Address - Country:US
Practice Address - Phone:512-572-6634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-20
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX849521133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered