Basic Information
| Provider Information | |||||||||
| NPI: | 1891418547 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LONGWELL | ||||||||
| FirstName: | MALLORY | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | MS, RD, LD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2425 ASHDALE DR APT 40 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787578151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9135931409 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5225 N LAMAR BLVD | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787511820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124724357 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2022 | ||||||||
| LastUpdateDate: | 09/19/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | DT87204 | TX | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.