Provider Demographics
NPI:1790722015
Name:WALLACE, MAUREEN PATRICIA (RD)
Entity Type:Individual
Prefix:MS
First Name:MAUREEN
Middle Name:PATRICIA
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:PO BOX 1698
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33757-1698
Mailing Address - Country:US
Mailing Address - Phone:727-532-0002
Mailing Address - Fax:
Practice Address - Street 1:753 VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:DUNEDIN
Practice Address - State:FL
Practice Address - Zip Code:34698-6615
Practice Address - Country:US
Practice Address - Phone:727-734-6888
Practice Address - Fax:727-734-6898
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND4693133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU7098YMedicare PIN