Provider Demographics
NPI:1134663297
Name:HALLARE, MARY GRACE (RD)
Entity Type:Individual
Prefix:MS
First Name:MARY GRACE
Middle Name:
Last Name:HALLARE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3437 CAROLINE ST
Mailing Address - Street 2:ROOM 3076
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-1111
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3437 CAROLINE ST
Practice Address - Street 2:ROOM 3076
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1111
Practice Address - Country:US
Practice Address - Phone:314-977-8523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-08
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86043967133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered