Healthcare Provider Details

I. General information

NPI: 1316579105
Provider Name (Legal Business Name): SHAUNICE WALL DIETITIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2020
Last Update Date: 02/10/2020
Certification Date: 02/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 ATLANTIC ST SW
WASHINGTON DC
20032-2350
US

IV. Provider business mailing address

4 ATLANTIC ST SW
WASHINGTON DC
20032-2350
US

V. Phone/Fax

Practice location:
  • Phone: 202-407-7747
  • Fax: 202-232-8494
Mailing address:
  • Phone: 202-407-7747
  • Fax: 202-232-8494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDI100000712
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: