Provider Demographics
NPI:1285224824
Name:WALLACE, ELIZABETH (RD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name: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 1:11607 INVIDIA CT
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93312-6521
Mailing Address - Country:US
Mailing Address - Phone:661-487-7401
Mailing Address - Fax:
Practice Address - Street 1:11607 INVIDIA CT
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93312-6521
Practice Address - Country:US
Practice Address - Phone:661-487-7401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-18
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86291274133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered