MEDICARE: MALLORY JOHNS MS, RD

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
1	133V00000X	Registered Dietitian	LD006621	GA

General Provider Information

NPI Number	:	1720884638
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MALLORY JOHNS MS, RD

Provider Business Mailing Address
First Line	:	2327 WOODBINE RD
Second Line	:
City	:	AUGUSTA
State	:	GA
Zip	:	30904-3153
Country	:	US
Telephone Number	:	229-376-3028
Fax Number	:

Provider Business Practice Location Address
First Line	:	2327 WOODBINE RD
Second Line	:
City	:	AUGUSTA
State	:	GA
Zip	:	30904-3153
Country	:	US
Telephone Number	:	229-376-3028
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/21/2025
Last Update Date	:	02/21/2025

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