Shannon Rae Mallory Hertzog, BS, MS

Primary specialty

Registered DietitianTaxonomy code 133V00000X

License

DI61176521 Issued in WA

Practice address

1615 Delaware St
Longview, WA 98632-2367

Phone

(360) 501-3601

Fax

(360) 501-3648

NPI assigned

May 11, 2021

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in WA

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Bachelor of Science, Master of Science

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Peacehealth

  • Multi-Specialty Clinic/Center
  • Longview, WA
  • NPI 1720056187

  Dietitian, Registered

  Medicare reassignment NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1620691200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1766188800000",
    "number": "1124602560",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "700 NE 87TH AVE",
            "city": "VANCOUVER",
            "state": "WA",
            "postal_code": "986644896",
            "telephone_number": "360-882-2778"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1615 DELAWARE ST",
            "city": "LONGVIEW",
            "state": "WA",
            "postal_code": "986322367",
            "telephone_number": "360-501-3601",
            "fax_number": "360-501-3648"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "2005 W Main St Ste 130",
            "address_purpose": "LOCATION",
            "city": "Battle Ground",
            "state": "WA",
            "postal_code": "986044311",
            "country_code": "US",
            "telephone_number": "360-882-2778",
            "fax_number": "360-604-1785",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "HERTZOG",
        "first_name": "SHANNON",
        "middle_name": "RAE MALLORY",
        "credential": "BS, MS",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2021-05-11",
        "last_updated": "2025-12-20",
        "certification_date": "2025-12-20",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "133V00000X",
            "taxonomy_group": "",
            "desc": "Dietitian, Registered",
            "state": "WA",
            "license": "DI61176521",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Jessica Lassette Hernandez-Gonzales, PT, DPT
• Joseph Phillip Hernandez
• Evelyn R Heroux
• Katy Arleen Herr, PSY.D
• James Robert Herron III, AAC
• Kathleen Herzog, PA-C
• Raven Herzog
• Lisa Kainani Hewahewa
• Mindi Marie Hiatt
• Thomas A Hickey, MD

• Registered Dietitian in Longview, WA
• Providers in Longview, WA by specialty
• Registered Dietitian in Washington

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 20, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.