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General NPI Number Information
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NPI Number | 1811318942
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Entity Type | Individual
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Provider Name | ANNA LAUREN WALLACE RD, LD
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Gender | Female
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Dates
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Enumeration Date | 12/16/2013
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Last Update Date | 12/26/2013
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Provider Practice Location Address
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Address Line | 102 N. MAIN ST.
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City | MENDENHALL
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State | MS
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Zip | 39114
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Country | US
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Telephone | 601-847-2511
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Fax | 601-847-0931
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Provider Business Mailing Address
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Address Line | 102 N. MAIN ST.
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City | MENDENHALL
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State | MS
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Zip | 39114
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Country | US
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Telephone | 601-847-2511
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Fax | 601-847-0931
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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 | D1609
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License Number State | MS
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