Provider Demographics
NPI:1700178779
Name:WALLACE, ELLEN EASLEY (CDE, RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:EASLEY
Last Name:WALLACE
Suffix:
Gender:F
Credentials:CDE, RD, LD
Other - Prefix:MISS
Other - First Name:ELLEN
Other - Middle Name:JANE
Other - Last Name:EASLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 5333
Mailing Address - Street 2:
Mailing Address - City:MISSISSIPPI STATE
Mailing Address - State:MS
Mailing Address - Zip Code:39762-5333
Mailing Address - Country:US
Mailing Address - Phone:662-418-1184
Mailing Address - Fax:
Practice Address - Street 1:103 STARR AVE APT 66
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-4058
Practice Address - Country:US
Practice Address - Phone:662-418-1184
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-10
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSD1317133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered