Provider Demographics
NPI:1023535440
Name:WALLACE, GRETCHEN COLEMAN (MS, RD, LD, CD)
Entity Type:Individual
Prefix:MRS
First Name:GRETCHEN
Middle Name:COLEMAN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MS, RD, LD, CD
Other - Prefix:
Other - First Name:GRETCHEN
Other - Middle Name:MARIE
Other - Last Name:COLEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6 CARDINAL WAY STE 900
Mailing Address - Street 2:
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63102
Mailing Address - Country:US
Mailing Address - Phone:360-209-2075
Mailing Address - Fax:206-681-9640
Practice Address - Street 1:6 CARDINAL WAY
Practice Address - Street 2:SUITE 900
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63102
Practice Address - Country:US
Practice Address - Phone:360-209-2075
Practice Address - Fax:206-681-9640
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-25
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023005984133V00000X
133V00000X
OR10235828133V00000X
WADI60956654133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered