Provider Demographics
NPI:1982156766
Name:WALLACE, MARY TERESE
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:TERESE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TERESE
Other - Middle Name:
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RDN
Mailing Address - Street 1:700 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-4302
Mailing Address - Country:US
Mailing Address - Phone:206-720-3734
Mailing Address - Fax:206-292-2163
Practice Address - Street 1:939 CAROLINE ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-3997
Practice Address - Country:US
Practice Address - Phone:360-417-7125
Practice Address - Fax:360-417-7188
Is Sole Proprietor?:No
Enumeration Date:2016-10-27
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI 60685427133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered