Provider Demographics
NPI:1477963650
Name:MALLORY, MICHELLE (RD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:MALLORY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:NORTHUP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2345 E. PRATER WAY, SUITE 207
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:NV
Mailing Address - Zip Code:89434
Mailing Address - Country:US
Mailing Address - Phone:775-356-9393
Mailing Address - Fax:775-356-5590
Practice Address - Street 1:3802 MEADOWS LN
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89107-3112
Practice Address - Country:US
Practice Address - Phone:702-313-8446
Practice Address - Fax:702-221-8446
Is Sole Proprietor?:No
Enumeration Date:2014-04-28
Last Update Date:2017-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV86028933133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1477963650Medicaid
NV1477963650Medicaid