Provider Demographics
NPI:1407927239
Name:LEWALLEN, CHRISTINE MARIE (RD)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:MARIE
Last Name:LEWALLEN
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 1:3143 SEA GULL LN
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-4604
Mailing Address - Country:US
Mailing Address - Phone:209-483-7647
Mailing Address - Fax:
Practice Address - Street 1:2233 GRAND CANAL BLVD STE 106
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-6657
Practice Address - Country:US
Practice Address - Phone:209-483-7647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA876533133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered