Provider Demographics
NPI:1851305304
Name:WALLACE, MINDY LEE (RD LDN)
Entity Type:Individual
Prefix:MS
First Name:MINDY
Middle Name:LEE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:RD LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2820 E BLUFF CT
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62305-1329
Mailing Address - Country:US
Mailing Address - Phone:217-440-6458
Mailing Address - Fax:
Practice Address - Street 1:935 JERSEY ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-4030
Practice Address - Country:US
Practice Address - Phone:217-228-2413
Practice Address - Fax:217-228-2416
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2008-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164003636133V00000X
MO2005004105133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL00132009OtherBLUE CROSS BLUE SHIELD IL
IL075113OtherQUINCY HEALTH CARE MANAGE
IL075113OtherQUINCY HEALTH CARE MANAGE