Provider Demographics
NPI:1750721403
Name:CLAVELLE, MARY A (RD, LDN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:CLAVELLE
Suffix:
Gender:F
Credentials:RD, LDN
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 770
Mailing Address - Street 2:
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-0770
Mailing Address - Country:US
Mailing Address - Phone:225-306-2000
Mailing Address - Fax:
Practice Address - Street 1:6351 MAIN ST
Practice Address - Street 2:
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791-4038
Practice Address - Country:US
Practice Address - Phone:225-306-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-26
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1147133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered