1265707079 NPI number — MS. MALLORY KAY TABAK MS, RD, LD

Table of content: MS. MALLORY KAY TABAK MS, RD, LD (NPI 1265707079)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265707079 NPI number — MS. MALLORY KAY TABAK MS, RD, LD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TABAK
Provider First Name:
MALLORY
Provider Middle Name:
KAY
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MS, RD, LD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265707079
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/04/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2063 JESSE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUDSON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44236-4217
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-760-3718
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
416 ROANOKE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CUYAHOGA FALLS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44221-1549
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-760-3718
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/12/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  6771 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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