Provider Demographics
NPI:1710141890
Name:MALLO, JO ANN MARIE (MS RD CDN)
Entity Type:Individual
Prefix:MS
First Name:JO ANN
Middle Name:MARIE
Last Name:MALLO
Suffix:
Gender:F
Credentials:MS RD CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:452 WHITEHAVEN RD
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:14072
Mailing Address - Country:US
Mailing Address - Phone:716-773-3309
Mailing Address - Fax:
Practice Address - Street 1:452 WHITE HAVEN RD
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NY
Practice Address - Zip Code:14072
Practice Address - Country:US
Practice Address - Phone:716-773-3309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-17
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209919133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered