Provider Demographics
NPI:1962537522
Name:MALLOY, LISA (RD)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:
Last Name:MALLOY
Suffix:
Gender:F
Credentials:RD
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Mailing Address - Street 1:23500 US HIGHWAY 160
Mailing Address - Street 2:SPANISH PEAKS REGIONAL HEALTH CENTER
Mailing Address - City:WALSENBURG
Mailing Address - State:CO
Mailing Address - Zip Code:81089-9524
Mailing Address - Country:US
Mailing Address - Phone:719-738-5100
Mailing Address - Fax:719-738-5138
Practice Address - Street 1:23500 US HIGHWAY 160
Practice Address - Street 2:SPANISH PEAKS REGIONAL HEALTH CENTER
Practice Address - City:WALSENBURG
Practice Address - State:CO
Practice Address - Zip Code:81089-9524
Practice Address - Country:US
Practice Address - Phone:719-738-5100
Practice Address - Fax:719-738-5138
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO810059133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO481228Medicare UPIN