Provider Demographics
NPI:1528156783
Name:MALLERY, JANE MILLAR (RD)
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:MILLAR
Last Name:MALLERY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:JANE
Other - Middle Name:
Other - Last Name:MILLAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:965 FLYING EAGLE PL
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919-1601
Mailing Address - Country:US
Mailing Address - Phone:719-533-0607
Mailing Address - Fax:
Practice Address - Street 1:4102 PINION DR
Practice Address - Street 2:
Practice Address - City:USAF ACADEMY
Practice Address - State:CO
Practice Address - Zip Code:80840-2502
Practice Address - Country:US
Practice Address - Phone:719-333-5071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered