Provider Demographics
NPI:1457850703
Name:MALECKAS, CRYSTAL (RD,LD)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:MALECKAS
Suffix:
Gender:F
Credentials:RD,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 LOVEWELL LOOP
Mailing Address - Street 2:
Mailing Address - City:RICHTON
Mailing Address - State:MS
Mailing Address - Zip Code:39476-7997
Mailing Address - Country:US
Mailing Address - Phone:601-606-9934
Mailing Address - Fax:
Practice Address - Street 1:210 BAY AVE
Practice Address - Street 2:
Practice Address - City:RICHTON
Practice Address - State:MS
Practice Address - Zip Code:39476-9665
Practice Address - Country:US
Practice Address - Phone:601-606-9934
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-01
Last Update Date:2018-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSD1841133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered