Provider Demographics
NPI:1033862362
Name:FENDA WALLACE, LISA (RD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:FENDA WALLACE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 WILLET AVE
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34108-2104
Mailing Address - Country:US
Mailing Address - Phone:216-409-1727
Mailing Address - Fax:
Practice Address - Street 1:430 WILLET AVE
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34108-2104
Practice Address - Country:US
Practice Address - Phone:216-409-1727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-27
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11012133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty