Provider Demographics
NPI:1720699945
Name:MCCONNIEL, BRENNA (RDN, LDN)
Entity Type:Individual
Prefix:
First Name:BRENNA
Middle Name:
Last Name:MCCONNIEL
Suffix:
Gender:F
Credentials:RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6071 VILLAGE BEND DR APT 103
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-3502
Mailing Address - Country:US
Mailing Address - Phone:214-794-3423
Mailing Address - Fax:
Practice Address - Street 1:6071 VILLAGE BEND DR APT 103
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75206-3502
Practice Address - Country:US
Practice Address - Phone:214-794-3423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-11
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT86372133V00000X
86117492133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
86117492OtherCOMMISSION ON DIETETIC REGISTRATION