Healthcare Provider Details

I. General information

NPI: 1376019257
Provider Name (Legal Business Name): MALLORY MORTON RDN, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2018
Last Update Date: 10/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1102 N PINE RD
OLLA LA
71465-4804
US

IV. Provider business mailing address

1809 E GEORGIA AVE
RUSTON LA
71270-4062
US

V. Phone/Fax

Practice location:
  • Phone: 318-495-3131
  • Fax: 318-495-3229
Mailing address:
  • Phone: 318-471-8898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2588
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: