Provider Demographics
NPI:1497001333
Name:WALLACE, CINDY JEAN ANDREWS (RD, LDN, MBA)
Entity Type:Individual
Prefix:
First Name:CINDY JEAN
Middle Name:ANDREWS
Last Name:WALLACE
Suffix:
Gender:F
Credentials:RD, LDN, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:352 MERRITT RD
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:LA
Mailing Address - Zip Code:71006-4319
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3022 OLD MINDEN RD
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71112-2477
Practice Address - Country:US
Practice Address - Phone:318-741-7314
Practice Address - Fax:318-741-7441
Is Sole Proprietor?:No
Enumeration Date:2012-07-30
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA601842133N00000X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist