Healthcare Provider Details

I. General information

NPI: 1437732062
Provider Name (Legal Business Name): EMILY WALLACE RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2021
Last Update Date: 02/18/2024
Certification Date: 02/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 CIVIC CENTER BLVD
PHILADELPHIA PA
19104-4395
US

IV. Provider business mailing address

1814 PINE ST APT 1R
PHILADELPHIA PA
19103-6645
US

V. Phone/Fax

Practice location:
  • Phone: 215-285-9048
  • Fax:
Mailing address:
  • Phone: 215-285-9048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86098606
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: