Provider Demographics
NPI:1891405015
Name:WALLACE, SARAH (RDN)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:759 N 470 E
Mailing Address - Street 2:
Mailing Address - City:TREMONTON
Mailing Address - State:UT
Mailing Address - Zip Code:84337-6778
Mailing Address - Country:US
Mailing Address - Phone:385-205-9877
Mailing Address - Fax:
Practice Address - Street 1:500 EAST 1400 NORTH
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341
Practice Address - Country:US
Practice Address - Phone:435-716-5609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-29
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13117880-4901133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered