Provider Demographics
NPI:1073110318
Name:SANTAROSA MAHONEY, MARY ELIZABETH (RDN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:SANTAROSA MAHONEY
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:MAHONEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RDN
Mailing Address - Street 1:1322 COTULLA DR
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-4639
Mailing Address - Country:US
Mailing Address - Phone:408-655-4386
Mailing Address - Fax:
Practice Address - Street 1:1322 COTULLA DR
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-4639
Practice Address - Country:US
Practice Address - Phone:408-655-4386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-08
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT86654133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered