Provider Demographics
NPI:1194447250
Name:STAFFORD, MONIQUE IDELETTE-LOUW (RD)
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:IDELETTE-LOUW
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:MONIQUE
Other - Middle Name:IDELETTE
Other - Last Name:LOUW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:431 EBENEZER AVE
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29730-3539
Mailing Address - Country:US
Mailing Address - Phone:864-423-9937
Mailing Address - Fax:
Practice Address - Street 1:1131 SALUDA ST
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29730-5776
Practice Address - Country:US
Practice Address - Phone:803-325-8742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-15
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL007003133V00000X
SC2510133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered