Mary Elise Wallace, MSRD/LD

Primary specialty

Registered DietitianTaxonomy code 133V00000X

License

DT03189 Issued in TX

Practice address

6705 Heritage Pkwy Ste 104
Rockwall, TX 75087-8729

Phone

(972) 412-7700

NPI assigned

Dec 15, 2016

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1481760000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1628726400000",
    "number": "1013451608",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 127",
            "city": "ROCKWALL",
            "state": "TX",
            "postal_code": "750870127",
            "telephone_number": "972-412-7700",
            "fax_number": "972-412-7710"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6705 HERITAGE PKWY STE 104",
            "city": "ROCKWALL",
            "state": "TX",
            "postal_code": "750878729",
            "telephone_number": "972-412-7700"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "3600 Gaston Ave",
            "address_2": "Suite 656",
            "address_purpose": "LOCATION",
            "city": "Dallas",
            "state": "TX",
            "postal_code": "752461800",
            "country_code": "US",
            "telephone_number": "214-820-3896",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "MARY",
        "middle_name": "ELISE",
        "name_prefix": "Ms.",
        "credential": "MSRD/LD",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2016-12-15",
        "last_updated": "2021-08-12",
        "certification_date": "2021-08-12",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "133V00000X",
            "taxonomy_group": "",
            "desc": "Dietitian, Registered",
            "state": "TX",
            "license": "DT03189",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Wallace Orthopaedics and Sports Medicine
• Wallace Sports Medicine PA
• Brenda Wallace, PA-C
• Brittany Wallace, D.P.T.
• Jeffrey S Wallace, M.D.
• Gabriella Walton
• Kathy L. Wanderer, L.AC.
• Daniel Enoch Wandrey, M.D.
• Erin Wandrey
• Alexus Wanton

• Registered Dietitian in Rockwall, TX
• Providers in Rockwall, TX by specialty
• Registered Dietitian in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 12, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.