Provider Demographics
NPI:1811318942
Name:WALLACE, ANNA LAUREN (RD, LD)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:LAUREN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 N. MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:MENDENHALL
Mailing Address - State:MS
Mailing Address - Zip Code:39114
Mailing Address - Country:US
Mailing Address - Phone:601-847-2511
Mailing Address - Fax:601-847-0931
Practice Address - Street 1:102 N. MAIN ST.
Practice Address - Street 2:
Practice Address - City:MENDENHALL
Practice Address - State:MS
Practice Address - Zip Code:39114
Practice Address - Country:US
Practice Address - Phone:601-847-2511
Practice Address - Fax:601-847-0931
Is Sole Proprietor?:No
Enumeration Date:2013-12-16
Last Update Date:2013-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSD1609133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered