Provider Demographics
NPI:1720884638
Name:JOHNS, MALLORY (MS, RD)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:JOHNS
Suffix:
Gender:
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2327 WOODBINE RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-3153
Mailing Address - Country:US
Mailing Address - Phone:229-376-3028
Mailing Address - Fax:
Practice Address - Street 1:2327 WOODBINE RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-3153
Practice Address - Country:US
Practice Address - Phone:229-376-3028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-21
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD006621133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered