Provider Demographics
NPI:1013451608
Name:WALLACE, MARY ELISE (MSRD/LD)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ELISE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MSRD/LD
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 127
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75087-0127
Mailing Address - Country:US
Mailing Address - Phone:972-412-7700
Mailing Address - Fax:972-412-7710
Practice Address - Street 1:6705 HERITAGE PKWY STE 104
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75087-8729
Practice Address - Country:US
Practice Address - Phone:972-412-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-15
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT03189133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered