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SHANNON RAE MALLORY HERTZOG BS, MS
NPI 1124602560
Dietitian, Registered in Longview, WA

Active since May 11, 2021
1615 DELAWARE ST, LONGVIEW, WA 98632(360) 501-3601(360) 501-3648 Get Directions Write a Review

NPPES record last updated: December 20, 2025. Verified against the NPPES registry weekly; last sync: November 01, 2026.

Record update history: Dec 20, 2025, May 11, 2021 (2 updates tracked since 2021).

About Shannon Rae Mallory Hertzog Bs, Ms NPPES

Official registry information on file with the National Plan and Provider Enumeration System.

SHANNON RAE MALLORY HERTZOG BS, MS (NPI 1124602560) is an individual dietitian, registered in Longview, Washington, licensed in Washington (DI61176521) and active in the NPI registry since May 2021. She maintains a secondary practice location in Battle Ground.

NPPES Registry Identity

NPI1124602560
Entity TypeIndividualFemale
Primary Taxonomy133V00000X
Provider Legal NameSHANNON RAE MALLORY HERTZOGCredential: BS, MS
Location Address1615 DELAWARE STLongview, WA 98632-2367
Mailing Address700 Ne 87th AveVancouver, WA 98664-4896 · (360) 882-2778
Phone(360) 501-3601
Fax(360) 501-3648
Sole ProprietorNo
Enumeration DateMay 11, 2021
Last NPPES UpdateDecember 20, 20252 updates tracked since enumeration
NPPES CertifiedDecember 20, 2025
✔ NPI 1124602560 is a valid, active identifier and passes the ISO check-digit test.

Specialties & Licenses

★ Primary SpecialtyDietitian, RegisteredDietary & Nutritional Service Providers
Taxonomy Code133V00000X
License✔ Licensed in WA · DI61176521
Definition
A Registered Dietitian (RD)/Registered Dietitian Nutritionist (RDN) is an individual uniquely trained in the science of nutrition and practice of dietetics to design and provide medical nutrition therapy (MNT) and other evidence-based applications of the Nutrition Care Process (NCP) that exemplify the profession's systematic approach to providing high quality nutrition care. Registered dietitians provide MNT for the purpose of disease prevention or management, or to treat or rehabilitate an illness, injury, or condition, with the use of specific, indicated physical and cognitive nutrition care services comprised of one or more of the following aspects of the NCP: nutrition assessment/reassessment, nutrition diagnosis, nutrition intervention (e.g., nutrition counseling, therapeutic diet ordering, and nutrition education) and nutrition monitoring and evaluation.
1615 DELAWARE ST, Longview, WA 98632
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Secondary Practice Location 1

Location 12005 W Main St Ste 130Battle Ground, WA 98604-4311 · Phone (360) 882-2778 · Fax (360) 604-1785

Accepted Insurance

The full list of accepted plans is on the Insurance tab. Issuers include Ambetter Health, Moda Health Plan, Inc., PacificSource Health Plans and more.Insurance ›

Medicare Participation & PECOS CMS

Medicare enrollment, assignment, billing reassignment, and ordering and referring status from CMS.

Medicare Enrollment Status

✔

Enrolled in Medicare (PECOS)

Shannon Rae Mallory Hertzog Bs, Ms is registered in the CMS Provider Enrollment, Chain and Ownership System (PECOS).

Medicare Billing Reassignment

Medicare enrollment records show Shannon Hertzog reassigns Medicare billing to 1 organization. The organization bills Medicare for the services this provider delivers there.

Peacehealth
Same address
Multi-Specialty
1615 DELAWARE ST
Longview, WA 98632
  • Reassigned Medicare billing, Washington enrollment
  • 308 clinicians in this Medicare group
NPI 1720056187 (360) 414-2000

Source: CMS Revalidation Reassignment List, October 2026 release. Reassignment records can lag staffing changes; confirm a current affiliation with the organization.

Other Providers at the Same Location NPPES 20

Providers registered at the same practice address, or within the immediate area, according to the NPPES registry.

CHOONG R KIM M.D.
Radiology (Radiation Oncology)
1615 DELAWARE ST
LONGVIEW, WA 98632
Cowlitz County (360) 636-4841
DR. STEVEN ROBERT SPENCE JR. DNP, ARNP, FNP-BC
Nurse Practitioner (Family)
1615 DELAWARE ST
LONGVIEW, WA 98632
Cowlitz County (360) 816-5706
ALEXANDER SHAR MD
Internal Medicine (Hematology)
1615 DELAWARE ST
LONGVIEW, WA 98632
Cowlitz County (360) 414-7878
PETER J LEYZAC CRNA
Nurse Anesthetist, Certified Registered
1615 DELAWARE ST
LONGVIEW, WA 98632
Cowlitz County (360) 414-2000
CHRISTINE WILSON PHARMD
Pharmacist
1615 DELAWARE ST
LONGVIEW, WA 98632
Cowlitz County (360) 414-2000
HOLLY WELLS FNP-BC
Nurse Practitioner (Family)
1615 DELAWARE ST
LONGVIEW, WA 98632
Cowlitz County (360) 414-2385
ERIK THOMAS PIHL
Surgery
1615 DELAWARE ST
LONGVIEW, WA 98632
Cowlitz County (360) 501-3500
DR. KARA RUZICKA PHARMD
Pharmacist
1615 DELAWARE ST
LONGVIEW, WA 98632
Cowlitz County (360) 636-4808

Frequently Asked Questions NPPES & CMS

Common questions about this NPI record, answered from the official NPPES registry and CMS datasets shown on this page.

What is Shannon Hertzog's NPI number?

The NPI number for Shannon Hertzog is 1124602560. It was assigned to this individual provider in the NPPES registry on May 11, 2021.

Where is Shannon Hertzog located?

Shannon Hertzog practices at 1615 Delaware St, Longview, WA 98632. The listed phone number is (360) 501-3601.

What is Shannon Hertzog's specialty?

The primary specialty registered for this NPI is Dietitian, Registered with taxonomy code 133V00000X.

Is Shannon Hertzog enrolled in Medicare?

Yes. Shannon Hertzog is registered in the Medicare PECOS enrollment system.

Which organization bills Medicare for Shannon Hertzog's services?

According to the CMS Revalidation Reassignment List (October 2026 release), Shannon Hertzog reassigns Medicare benefits to Peacehealth (Longview, WA). The reassignment is filed with Medicare on form CMS-855R, signed by both the clinician and the organization, and lets the organization bill Medicare and receive payment for Shannon Hertzog's services. Reassignment records can lag staffing changes; confirm current arrangements with the organization.

What insurance does Shannon Hertzog accept?

Health plans from Ambetter Health, Moda Health Plan, Inc., PacificSource Health Plans and Premera Blue Cross Blue Shield of Alaska list Shannon Hertzog as in-network in at least one marketplace plan. Coverage varies by plan and year; verify with the insurer or the provider before a visit.

When was this NPI record last updated?

The NPPES record for Shannon Hertzog was last updated on December 20, 2025. NPI Profile syncs weekly with the NPPES registry data releases published by CMS. This NPI record was last updated 10 months ago. If this record has changed at CMS more recently, you can request an on-demand re-check against the live CMS registry, directly from this page.