Provider Demographics
NPI:1598159956
Name:WALLACE, ANGIE (NC)
Entity Type:Individual
Prefix:
First Name:ANGIE
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:NC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 EASTERLY PKWY
Mailing Address - Street 2:104
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16801-6300
Mailing Address - Country:US
Mailing Address - Phone:814-234-0785
Mailing Address - Fax:
Practice Address - Street 1:233 EASTERLY PKWY
Practice Address - Street 2:104
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16801-6300
Practice Address - Country:US
Practice Address - Phone:814-234-0785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-24
Last Update Date:2015-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist