Provider Demographics
NPI:1487711164
Name:GREY-MAHONEY, MELODESE (RD)
Entity type:Individual
Prefix:
First Name:MELODESE
Middle Name:
Last Name:GREY-MAHONEY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1766 STONE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-7441
Mailing Address - Country:US
Mailing Address - Phone:707-571-3101
Mailing Address - Fax:707-571-3294
Practice Address - Street 1:401 BICENTENNIAL WAY
Practice Address - Street 2:KAISER PERMANENTE MEDICAL CENTER
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-2149
Practice Address - Country:US
Practice Address - Phone:707-571-3101
Practice Address - Fax:707-571-3294
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered