Provider Demographics
NPI:1407616949
Name:BADER, FALLON (MS, RDN, LD)
Entity Type:Individual
Prefix:
First Name:FALLON
Middle Name:
Last Name:BADER
Suffix:
Gender:F
Credentials:MS, RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 CEDAR HILL PL NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87122-1906
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:139 BEAR HEAD CANYON RD UNIT B
Practice Address - Street 2:
Practice Address - City:JEMEZ PUEBLO
Practice Address - State:NM
Practice Address - Zip Code:87024-0776
Practice Address - Country:US
Practice Address - Phone:908-670-2348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-21
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNDP-2024-0036133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered