Provider Demographics
NPI:1891400131
Name:LAVIN, MALLORY GAIL (RDN, LD)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:GAIL
Last Name:LAVIN
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 DEREK DR
Mailing Address - Street 2:
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-6843
Mailing Address - Country:US
Mailing Address - Phone:636-866-5593
Mailing Address - Fax:
Practice Address - Street 1:1043 WOLFRUM RD
Practice Address - Street 2:
Practice Address - City:WELDON SPRING
Practice Address - State:MO
Practice Address - Zip Code:63304-7625
Practice Address - Country:US
Practice Address - Phone:314-517-7669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-20
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015026928133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered