Provider Demographics
NPI:1245755156
Name:WALLACE, JULIE (RD,LD,CSP)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:RD,LD,CSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3337 PREAKNESS CT
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-5553
Mailing Address - Country:US
Mailing Address - Phone:404-862-9337
Mailing Address - Fax:
Practice Address - Street 1:1229 JOHNSON FERRY RD STE 204B
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30068-5416
Practice Address - Country:US
Practice Address - Phone:404-692-6902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-11
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA86006561133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered