Provider Demographics
NPI:1891819769
Name:MALLOY, SAMANTHA JEAN (RD, LD)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JEAN
Last Name:MALLOY
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:JEAN
Other - Last Name:TOLLEFSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LD
Mailing Address - Street 1:12130 YUKON AVE N
Mailing Address - Street 2:
Mailing Address - City:CHAMPLIN
Mailing Address - State:MN
Mailing Address - Zip Code:55316-3582
Mailing Address - Country:US
Mailing Address - Phone:612-618-6724
Mailing Address - Fax:
Practice Address - Street 1:1 VETERANS DR
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55417-2309
Practice Address - Country:US
Practice Address - Phone:612-467-4374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-18
Last Update Date:2011-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2444133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered