Provider Demographics
NPI:1073110367
Name:MALLOY, ABIGAIL ELIZABETH (RDN, LDN)
Entity Type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:ELIZABETH
Last Name:MALLOY
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 1:713 HAWK RUN DR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-3778
Mailing Address - Country:US
Mailing Address - Phone:636-697-8118
Mailing Address - Fax:
Practice Address - Street 1:713 HAWK RUN DR
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-3778
Practice Address - Country:US
Practice Address - Phone:636-697-8118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-08
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019029423133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered