Provider Demographics
NPI:1437276052
Name:MALLORY, JULIE ANN (MS,RD,LD)
Entity Type:Individual
Prefix:MS
First Name:JULIE
Middle Name:ANN
Last Name:MALLORY
Suffix:
Gender:F
Credentials:MS,RD,LD
Other - Prefix:MS
Other - First Name:JULIE
Other - Middle Name:ANN
Other - Last Name:MALLORY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS,RD,LD
Mailing Address - Street 1:31413 HIGHWAY 9
Mailing Address - Street 2:
Mailing Address - City:TECUMSEH
Mailing Address - State:OK
Mailing Address - Zip Code:74873-5523
Mailing Address - Country:US
Mailing Address - Phone:405-307-1697
Mailing Address - Fax:405-307-2124
Practice Address - Street 1:31413 HIGHWAY 9
Practice Address - Street 2:
Practice Address - City:TECUMSEH
Practice Address - State:OK
Practice Address - Zip Code:74873-5523
Practice Address - Country:US
Practice Address - Phone:405-205-0935
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKLD693133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered