Provider Demographics
NPI:1780770081
Name:CONNELL, RANDALL (RD)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:
Last Name:CONNELL
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 WINDCHASE DR
Mailing Address - Street 2:PO BOX 52009
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-6546
Mailing Address - Country:US
Mailing Address - Phone:337-289-7584
Mailing Address - Fax:337-289-7579
Practice Address - Street 1:1214 COOLIDGE BLVD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2621
Practice Address - Country:US
Practice Address - Phone:337-289-7584
Practice Address - Fax:337-289-7579
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1964133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education