Susan Elizabeth Wallace, R,D., L.D.
Individual provider Active NPI Registered Dietitian · Lakeside Park, KY
NPI 1376842732 · NPPES record last updated Mar 23, 2011
Key facts
- NPI
- 1376842732
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Registered Dietitian 133V00000X
- License
- KY-1998 (KY)
- Practice address
- 102 Carran Dr
Lakeside Park, KY 41017-2233 - Phone
- (859) 331-2939
- NPI assigned
- Mar 23, 2011
- Sex
- Female
- Sole proprietor
- Yes
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| KY-1998 | KY | MD | Registered Dietitian |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Registered Dietitian | 133V00000X | KY-1998 | KY | Yes |
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
Other providers in Lakeside Park, KY
- Strategic Wellness, LLC
- Transcare of Kentucky, Inc.
- Nichole Violet Tucker
- Jessica R Vaniglia
- Manuel Santos Villareal
- Shannon Wehrman
- Emily M Woeste
All providers in Lakeside Park, KY · Registered Dietitian in Kentucky
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Mar 23, 2011. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.