Provider Demographics
NPI:1841219318
Name:WALLACE, DIANE E (RD, CDE, RMT)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:E
Last Name:WALLACE
Suffix:
Gender:F
Credentials:RD, CDE, RMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9109 CHARDIN PARK DR
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-7626
Mailing Address - Country:US
Mailing Address - Phone:817-798-8977
Mailing Address - Fax:
Practice Address - Street 1:3105 W ARKANSAS LN
Practice Address - Street 2:SUITE B-1
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76016-5721
Practice Address - Country:US
Practice Address - Phone:817-798-8977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT04296133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX612078Medicare ID - Type Unspecified