Provider Demographics
NPI:1912189127
Name:MALONE, ANASTASIA E (MS, RD, LD, CPT)
Entity Type:Individual
Prefix:
First Name:ANASTASIA
Middle Name:E
Last Name:MALONE
Suffix:
Gender:F
Credentials:MS, RD, LD, CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 S LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-3420
Mailing Address - Country:US
Mailing Address - Phone:217-793-4367
Mailing Address - Fax:
Practice Address - Street 1:1701 S LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-3420
Practice Address - Country:US
Practice Address - Phone:217-793-4367
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-29
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164001711133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL203892Medicare PIN