Provider Demographics
NPI:1629825880
Name:MCGINNIS, MOLLY (RDN)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:MCGINNIS
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 LINNVIEW DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63129-3847
Mailing Address - Country:US
Mailing Address - Phone:618-719-5748
Mailing Address - Fax:
Practice Address - Street 1:1161 FORTUNE BLVD STE 200
Practice Address - Street 2:
Practice Address - City:SHILOH
Practice Address - State:IL
Practice Address - Zip Code:62269-7385
Practice Address - Country:US
Practice Address - Phone:314-804-1848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-03
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023038357133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered