Provider Demographics
NPI:1326443433
Name:MALLORY, SHARRY D
Entity Type:Individual
Prefix:MRS
First Name:SHARRY
Middle Name:D
Last Name:MALLORY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHARRY
Other - Middle Name:D
Other - Last Name:MALLORY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD LD
Mailing Address - Street 1:459 N SLATE CUT RD
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47170-6513
Mailing Address - Country:US
Mailing Address - Phone:812-752-4786
Mailing Address - Fax:
Practice Address - Street 1:400 E GRAY ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1740
Practice Address - Country:US
Practice Address - Phone:502-574-6580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-31
Last Update Date:2014-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-0509133V00000X
IN37001258A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered