Basic Information
| Provider Information | |||||||||
| NPI: | 1134754500 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALLON | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | RDN, LD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 142 ELM RIDGE DR | ||||||||
| Address2: | |||||||||
| City: | NORTH LIBERTY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 523179412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5635083857 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2701 PRAIRIE MEADOW DR | ||||||||
| Address2: | |||||||||
| City: | IOWA CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 522428001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193847070 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2020 | ||||||||
| LastUpdateDate: | 03/06/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133VN1501X | 098024 | IA | Y |
No ID Information.