Provider Demographics
NPI:1093345423
Name:OVALLE, MARY CLARE (RD, IBCLC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CLARE
Last Name:OVALLE
Suffix:
Gender:F
Credentials:RD, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10290 N DEARING AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93730-4772
Mailing Address - Country:US
Mailing Address - Phone:559-304-0348
Mailing Address - Fax:
Practice Address - Street 1:10290 N DEARING AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93730-4772
Practice Address - Country:US
Practice Address - Phone:559-304-0348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-24
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA655589133V00000X
CAL-28731174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty