Provider Demographics
NPI:1508551433
Name:WALLACE, KELLI B (RD)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:B
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 1:2138 NC HIGHWAY 42 W
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NC
Mailing Address - Zip Code:27520-5300
Mailing Address - Country:US
Mailing Address - Phone:919-585-8777
Mailing Address - Fax:
Practice Address - Street 1:2138 NC HIGHWAY 42 W
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:NC
Practice Address - Zip Code:27520-5300
Practice Address - Country:US
Practice Address - Phone:919-585-8777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-06
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC004064133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered