Provider Demographics
NPI:1720506512
Name:MU-TAGALOA WALKER, MARY RITA (REGISTERED DIETITIAN)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:RITA
Last Name:MU-TAGALOA WALKER
Suffix:
Gender:F
Credentials:REGISTERED DIETITIAN
Other - Prefix:MRS
Other - First Name:MARY
Other - Middle Name:RITA
Other - Last Name:MU-TAGALOA WALKER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MARY WALKER RD/LD
Mailing Address - Street 1:338 SOUTH DAKOTA AVE, BLDG 13850 VANDENBERG AFB, CA 934
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AA
Mailing Address - Zip Code:93469
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:338 S DAKOTA AVE BLDG 13850
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93437-6307
Practice Address - Country:US
Practice Address - Phone:214-684-0947
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-31
Last Update Date:2020-03-16
Deactivation Date:2017-11-06
Deactivation Code:
Reactivation Date:2020-03-05
Provider Licenses
StateLicense IDTaxonomies
IL835750133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL835750OtherAMERICAN DIETETIC ASSOCIATION COMMISSION OF DIETETICS