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General NPI Number Information
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NPI Number | 1902795834
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Entity Type | Individual
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Provider Name | MALLORY SUE HANSEN RD
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Gender | Female
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Dates
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Enumeration Date | 07/03/2025
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Last Update Date | 07/03/2025
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Provider Practice Location Address
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Address Line | 501 6TH AVE S
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City | ST PETERSBURG
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State | FL
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Zip | 33701-4634
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Country | US
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Telephone | 727-898-7451
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Fax |
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Provider Business Mailing Address
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Address Line | 1661 CENTRAL AVE UNIT 6016
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City | ST PETERSBURG
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State | FL
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Zip | 33713-9083
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Country | US
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Telephone | 419-601-0304
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133VN1004X
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Taxonomy Name | Pediatric Nutrition Registered Dietitian
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License Number | 14411
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License Number State | FL
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