Healthcare Provider Details

I. General information

NPI: 1629980412
Provider Name (Legal Business Name): MALLORY MURRAY RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 W INDUSTRIAL DR
O FALLON MO
63366-1926
US

IV. Provider business mailing address

18 W INDUSTRIAL DR
O FALLON MO
63366-1926
US

V. Phone/Fax

Practice location:
  • Phone: 314-626-3472
  • Fax: 314-499-9076
Mailing address:
  • Phone: 314-626-3472
  • Fax: 314-499-9076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2026045457
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: