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General NPI Number Information
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NPI Number | 1245755156
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Entity Type | Individual
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Provider Name | JULIE WALLACE RD,LD,CSP
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Gender | Female
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Dates
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Enumeration Date | 08/11/2017
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Last Update Date | 07/27/2023
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Provider Practice Location Address
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Address Line | 1229 JOHNSON FERRY RD STE 204B
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City | MARIETTA
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State | GA
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Zip | 30068-5416
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Country | US
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Telephone | 404-692-6902
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Fax |
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Provider Business Mailing Address
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Address Line | 3337 PREAKNESS CT
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City | MARIETTA
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State | GA
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Zip | 30062-5553
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Country | US
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Telephone | 404-862-9337
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number | 86006561
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License Number State | GA
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