Provider Demographics
NPI:1104246024
Name:WALLNER, CASEY MAST (RD, LD)
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:MAST
Last Name:WALLNER
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:CASEY
Other - Middle Name:LYNN
Other - Last Name:MAST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LD
Mailing Address - Street 1:5280 NE SHELL WORLD PL
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97365-1246
Mailing Address - Country:US
Mailing Address - Phone:541-579-1823
Mailing Address - Fax:541-833-5005
Practice Address - Street 1:5280 NE SHELL WORLD PL
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-1246
Practice Address - Country:US
Practice Address - Phone:541-579-1823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-17
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLDD10158382133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered