Provider Demographics
NPI:1740425248
Name:WALLACE, TRUDY (RD)
Entity type:Individual
Prefix:
First Name:TRUDY
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 E 2ND ST
Mailing Address - Street 2:SUITE 402
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-1262
Mailing Address - Country:US
Mailing Address - Phone:775-982-5073
Mailing Address - Fax:775-982-5064
Practice Address - Street 1:1500 E 2ND ST
Practice Address - Street 2:SUITE 402
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-1262
Practice Address - Country:US
Practice Address - Phone:775-982-5073
Practice Address - Fax:775-982-5064
Is Sole Proprietor?:No
Enumeration Date:2008-12-11
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV36555Medicare PIN