Provider Demographics
NPI:1164545778
Name:MALONY, SUSAN (MS, RD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:MALONY
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1086
Mailing Address - Street 2:
Mailing Address - City:YREKA
Mailing Address - State:CA
Mailing Address - Zip Code:96097-1086
Mailing Address - Country:US
Mailing Address - Phone:530-842-9685
Mailing Address - Fax:530-842-7971
Practice Address - Street 1:101 E OBERLIN RD
Practice Address - Street 2:
Practice Address - City:YREKA
Practice Address - State:CA
Practice Address - Zip Code:96097-9553
Practice Address - Country:US
Practice Address - Phone:530-842-4445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL462546133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL462546OtherDIETETIC REGISTRATION