Provider Demographics
NPI:1891332276
Name:WALLIS, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:WALLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 OAKWOOD ST
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13440-3806
Mailing Address - Country:US
Mailing Address - Phone:315-525-3134
Mailing Address - Fax:
Practice Address - Street 1:315 OAKWOOD ST
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13440-3806
Practice Address - Country:US
Practice Address - Phone:315-525-3134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-05
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education