Basic Information
| Provider Information | |||||||||
| NPI: | 1073150926 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NEAL | ||||||||
| FirstName: | MARY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 777 AVENUE H | ||||||||
| Address2: | |||||||||
| City: | POWELL | ||||||||
| State: | WY | ||||||||
| PostalCode: | 824352260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077542267 | ||||||||
| FaxNumber: | 3077547733 | ||||||||
| Practice Location | |||||||||
| Address1: | 777 AVENUE H | ||||||||
| Address2: | |||||||||
| City: | POWELL | ||||||||
| State: | WY | ||||||||
| PostalCode: | 824352260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077542267 | ||||||||
| FaxNumber: | 3077547733 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2019 | ||||||||
| LastUpdateDate: | 12/10/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/10/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 061 | WY | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.