Provider Demographics
NPI:1477207611
Name:CALLAWAY, MALLORY (RD)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:CALLAWAY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 232410
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92193-2410
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4303 LA JOLLA VILLAGE DR STE 2110
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92122-1396
Practice Address - Country:US
Practice Address - Phone:858-657-8857
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-07
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86005489133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered