Provider Demographics
NPI:1548804370
Name:BAERENWALD, MALLORY H (MS,RD,CD)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:H
Last Name:BAERENWALD
Suffix:
Gender:F
Credentials:MS,RD,CD
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:H
Other - Last Name:KRUEGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS,RD,CD
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7222
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:3263 EATON RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-6830
Practice Address - Country:US
Practice Address - Phone:920-433-6700
Practice Address - Fax:920-433-6719
Is Sole Proprietor?:No
Enumeration Date:2019-11-05
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3465-29133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
86087767OtherCOMMISSION ON DIETETIC REGISTRATION