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NPI Code Detail

MEDICARE: MALLORY JO NICHOLSON RD, LD

MEDICARE: MALLORY JO NICHOLSON RD, LD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1133V00000XRegistered Dietitian002117IA

General Provider Information

NPI Number : 1154751196
Entity Type Code : Individual
Provider Name (Legal Business Name) : MALLORY JO NICHOLSON RD, LD
Provider Business Mailing Address
First Line : 1990 GRAND AVE
Second Line :
City : WEST DES MOINES
State : IA
Zip : 50265-4222
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 1990 GRAND AVE
Second Line :
City : WEST DES MOINES
State : IA
Zip : 50265-4222
Country : US
Telephone Number : 515-223-8151
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/12/2013
Last Update Date : 11/12/2013

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