Provider Demographics
NPI:1154399269
Name:SCOTT, CONNIE L (RD)
Entity type:Individual
Prefix:MS
First Name:CONNIE
Middle Name:L
Last Name:SCOTT
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:408 RIVERSIDE LN
Mailing Address - Street 2:
Mailing Address - City:STELLA
Mailing Address - State:NC
Mailing Address - Zip Code:28582-9723
Mailing Address - Country:US
Mailing Address - Phone:910-467-1313
Mailing Address - Fax:910-450-4559
Practice Address - Street 1:100 BREWSTER BLVD
Practice Address - Street 2:
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28547-2538
Practice Address - Country:US
Practice Address - Phone:910-450-4056
Practice Address - Fax:910-450-4559
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL723049133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered