MEDICARE: MARY INSALACO LICENSE DIETITIAN

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	2009014930	MO

General Provider Information

NPI Number	:	1780917237
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY INSALACO LICENSE DIETITIAN

Provider Business Mailing Address
First Line	:	2220 LEMP AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63104-2700
Country	:	US
Telephone Number	:	314-814-8615
Fax Number	:	314-814-8542

Provider Business Practice Location Address
First Line	:	3115 WYNFIELD TERRACE CT
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63129-3971
Country	:	US
Telephone Number	:	314-695-0797
Fax Number	:

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

Provider Enumeration Date	:	09/16/2009
Last Update Date	:	04/07/2026

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