Provider Demographics
NPI:1154751196
Name:NICHOLSON, MALLORY JO (RD, LD)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:JO
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:JO
Other - Last Name:SMALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1990 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50265-4222
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1990 GRAND AVE
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50265-4222
Practice Address - Country:US
Practice Address - Phone:515-223-8151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-12
Last Update Date:2013-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA002117133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered