Active NPI
Susan Elizabeth Wallace, R,D., L.D.
- Registered Dietitian
- Lakeside Park, KY
National Provider Identifier
1376842732
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Registered Dietitian
- License
- KY-1998
- Practice address
- 102 Carran Dr
Lakeside Park, KY 41017-2233 - Phone
- (859) 331-2939
- NPI assigned
- Mar 23, 2011
- Last updated
- Mar 23, 2011
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Registered Dietitian | 133V00000X | KY-1998 | KY | Primary |
Addresses
Primary practice location
102 Carran Dr
Lakeside Park, KY 41017-2233
Mailing address
102 Carran Dr
Lakeside Park, KY 41017-2233
Phone (859) 331-2939
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| KY-1998 | KY | MD | Registered Dietitian |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1300838400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1300838400000",
"number": "1376842732",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "102 CARRAN DR",
"city": "LAKESIDE PARK",
"state": "KY",
"postal_code": "410172233",
"telephone_number": "859-331-2939"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "102 CARRAN DR",
"city": "LAKESIDE PARK",
"state": "KY",
"postal_code": "410172233",
"telephone_number": "859-331-2939"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WALLACE",
"first_name": "SUSAN",
"middle_name": "ELIZABETH",
"credential": "R,D., L.D.",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2011-03-23",
"last_updated": "2011-03-23",
"status": "A"
},
"taxonomies": [
{
"code": "133V00000X",
"taxonomy_group": "",
"desc": "Dietitian, Registered",
"state": "KY",
"license": "KY-1998",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Lakeside Park, KY
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 23, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.