Provider Demographics
NPI:1336467612
Name:MALLEY, STEPHANIE TERESE (RD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:TERESE
Last Name:MALLEY
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 1:611 EAST DOUGLAS ROAD
Mailing Address - Street 2:SUITE 405
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-1468
Mailing Address - Country:US
Mailing Address - Phone:574-335-6240
Mailing Address - Fax:574-335-6241
Practice Address - Street 1:611 EAST DOUGLAS ROAD
Practice Address - Street 2:SUITE 405
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-1468
Practice Address - Country:US
Practice Address - Phone:574-335-6240
Practice Address - Fax:574-335-6241
Is Sole Proprietor?:No
Enumeration Date:2010-05-11
Last Update Date:2010-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37001711A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered