Provider Demographics
NPI:1902403611
Name:SHANNON, MALLORY (RD, LD)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:SHANNON
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:
Other - Last Name:STINSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:PO BOX 707001
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74170-7001
Mailing Address - Country:US
Mailing Address - Phone:888-247-0125
Mailing Address - Fax:918-502-8001
Practice Address - Street 1:6565 S YALE AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-8327
Practice Address - Country:US
Practice Address - Phone:918-491-3700
Practice Address - Fax:918-481-4063
Is Sole Proprietor?:No
Enumeration Date:2020-10-06
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2529133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200940470AMedicaid