Healthcare Provider Details

I. General information

NPI: 1245755156
Provider Name (Legal Business Name): JULIE WALLACE RD,LD,CSP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2017
Last Update Date: 07/27/2023
Certification Date: 07/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1229 JOHNSON FERRY RD STE 204B
MARIETTA GA
30068-5416
US

IV. Provider business mailing address

3337 PREAKNESS CT
MARIETTA GA
30062-5553
US

V. Phone/Fax

Practice location:
  • Phone: 404-692-6902
  • Fax:
Mailing address:
  • Phone: 404-862-9337
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86006561
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: