Provider Demographics
NPI:1760532113
Name:WALLACE, KAREN L (RD, CD)
Entity Type:Individual
Prefix:MS
First Name:KAREN
Middle Name:L
Last Name:WALLACE
Suffix:
Gender:F
Credentials:RD, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15418 MAIN STREET
Mailing Address - Street 2:SUITE 301
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012
Mailing Address - Country:US
Mailing Address - Phone:425-385-3262
Mailing Address - Fax:425-357-0924
Practice Address - Street 1:15418 MAIN ST
Practice Address - Street 2:STE 301
Practice Address - City:MILL CREEK
Practice Address - State:WA
Practice Address - Zip Code:98012-9030
Practice Address - Country:US
Practice Address - Phone:425-385-3262
Practice Address - Fax:425-357-0924
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00000485133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAB40129Medicare ID - Type UnspecifiedMEDICARE