Healthcare Provider Details

I. General information

NPI: 1861418535
Provider Name (Legal Business Name): LEE S. WALLACE MS, RD, LDN, FADA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 06/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 JEFFERSON AVE
MEMPHIS TN
38105-5003
US

IV. Provider business mailing address

711 JEFFERSON AVE
MEMPHIS TN
38105-5003
US

V. Phone/Fax

Practice location:
  • Phone: 901-448-6511
  • Fax: 901-448-7097
Mailing address:
  • Phone: 901-448-6511
  • Fax: 901-448-7097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License NumberLDN0000000356
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: