Provider Demographics
NPI:1235384082
Name:WALLEN, MARCIA L (MS, RD, LMNT)
Entity Type:Individual
Prefix:MS
First Name:MARCIA
Middle Name:L
Last Name:WALLEN
Suffix:
Gender:F
Credentials:MS, RD, LMNT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6001 VILLAGE DRIVE
Mailing Address - Street 2:HY-VEE
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516
Mailing Address - Country:US
Mailing Address - Phone:402-421-2462
Mailing Address - Fax:402-421-6517
Practice Address - Street 1:6001 VILLAGE DRIVE
Practice Address - Street 2:HY-VEE
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68516
Practice Address - Country:US
Practice Address - Phone:402-421-2462
Practice Address - Fax:402-421-6517
Is Sole Proprietor?:No
Enumeration Date:2008-11-20
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE882133V00000X
355564133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered