Provider Demographics
NPI:1811309875
Name:WALLACE, TARA ROBIN (RD LD)
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:ROBIN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:RD LD
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:ROBIN
Other - Last Name:KMENT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 ELM ST N
Mailing Address - Street 2:
Mailing Address - City:ONAMIA
Mailing Address - State:MN
Mailing Address - Zip Code:56359-7901
Mailing Address - Country:US
Mailing Address - Phone:320-532-3154
Mailing Address - Fax:320-532-3111
Practice Address - Street 1:200 ELM ST N
Practice Address - Street 2:
Practice Address - City:ONAMIA
Practice Address - State:MN
Practice Address - Zip Code:56359-7901
Practice Address - Country:US
Practice Address - Phone:320-532-3154
Practice Address - Fax:320-532-3111
Is Sole Proprietor?:No
Enumeration Date:2014-05-27
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2281133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered