Provider Demographics
NPI:1114519519
Name:MALLORY, ABIGAIL MARTHA HARRIS (RD, MS)
Entity Type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:MARTHA HARRIS
Last Name:MALLORY
Suffix:
Gender:F
Credentials:RD, MS
Other - Prefix:
Other - First Name:ABIGAIL
Other - Middle Name:MARTHA
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3413
Mailing Address - Street 2:
Mailing Address - City:KETCHUM
Mailing Address - State:ID
Mailing Address - Zip Code:83340-3369
Mailing Address - Country:US
Mailing Address - Phone:802-318-7232
Mailing Address - Fax:
Practice Address - Street 1:211 N 6TH AVE
Practice Address - Street 2:
Practice Address - City:HAILEY
Practice Address - State:ID
Practice Address - Zip Code:83333-8867
Practice Address - Country:US
Practice Address - Phone:802-318-7232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-07
Last Update Date:2021-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered