Healthcare Provider Details

I. General information

NPI: 1588119739
Provider Name (Legal Business Name): ALLYSON MAST RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2016
Last Update Date: 04/21/2023
Certification Date: 04/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2006 S MAIN ST
GOSHEN IN
46526-5232
US

IV. Provider business mailing address

PO BOX 834
GOSHEN IN
46527-0834
US

V. Phone/Fax

Practice location:
  • Phone: 574-237-8326
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: