Provider Demographics
NPI:1629394341
Name:WALLICK, ANGELA MARIE (MS, RDN, LDN)
Entity Type:Individual
Prefix:MISS
First Name:ANGELA
Middle Name:MARIE
Last Name:WALLICK
Suffix:
Gender:F
Credentials:MS, RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2164 NELSON AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-5760
Mailing Address - Country:US
Mailing Address - Phone:330-495-6402
Mailing Address - Fax:901-761-5933
Practice Address - Street 1:4515 POPLAR AVE STE 303
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38117-7507
Practice Address - Country:US
Practice Address - Phone:330-495-6402
Practice Address - Fax:901-761-5933
Is Sole Proprietor?:No
Enumeration Date:2010-04-20
Last Update Date:2016-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLDN0000002149133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered