MEDICARE: MS. MARY ANN KALONICK MS, RD, L/DN

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	LD-D-10232246	OR

General Provider Information

NPI Number	:	1073892964
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY ANN KALONICK MS, RD, L/DN

Provider Business Mailing Address
First Line	:	739 JACKSON ST W APT 4
Second Line	:
City	:	MONMOUTH
State	:	OR
Zip	:	97361-1340
Country	:	US
Telephone Number	:	352-228-3050
Fax Number	:

Provider Business Practice Location Address
First Line	:	739 JACKSON ST W
Second Line	:
City	:	MONMOUTH
State	:	OR
Zip	:	97361-1340
Country	:	US
Telephone Number	:	352-228-3050
Fax Number	:

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

Provider Enumeration Date	:	08/09/2011
Last Update Date	:	07/01/2025

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