Provider Demographics
NPI:1205560505
Name:COOPER, MALLORY ANN (RDN)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:ANN
Last Name:COOPER
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 MONARCH RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94597-2935
Mailing Address - Country:US
Mailing Address - Phone:925-487-6658
Mailing Address - Fax:
Practice Address - Street 1:500 MONARCH RIDGE DR
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94597-2935
Practice Address - Country:US
Practice Address - Phone:925-487-6658
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-12
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86175276133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty