Provider Demographics
NPI:1720604788
Name:WALLACE, NATALIE (MS, RDN)
Entity Type:Individual
Prefix:
First Name:NATALIE
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MS, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1736 E SYCAMORE AVE APT C
Mailing Address - Street 2:
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-3336
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1736 E SYCAMORE AVE APT C
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-3336
Practice Address - Country:US
Practice Address - Phone:916-952-6344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-24
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86069831133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered