1548804370 NPI number — MALLORY H BAERENWALD MS,RD,CD

Table of content: MALLORY H BAERENWALD MS,RD,CD (NPI 1548804370)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548804370 NPI number — MALLORY H BAERENWALD MS,RD,CD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BAERENWALD
Provider First Name:
MALLORY
Provider Middle Name:
H
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS,RD,CD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KRUEGER
Provider Other First Name:
MALLORY
Provider Other Middle Name:
H
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MS,RD,CD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1548804370
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/18/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 22487
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREEN BAY
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54305-2487
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-445-7222
Provider Business Mailing Address Fax Number:
920-445-7289

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3263 EATON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREEN BAY
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54311-6830
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-433-6700
Provider Business Practice Location Address Fax Number:
920-433-6719
Provider Enumeration Date:
11/05/2019

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:  3465-29 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 86087767 . This is a "COMMISSION ON DIETETIC REGISTRATION" identifier . This identifiers is of the category "OTHER".




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