Mary Terese Wallace

Primary specialty

Registered DietitianTaxonomy code 133V00000X

License

DI 60685427 Issued in WA

Practice address

939 Caroline St
Port Angeles, WA 98362-3997

Phone

(360) 417-7125

Fax

(360) 417-7188

NPI assigned

Oct 27, 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

Other names 1

• Terese Wallace Professional name

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": "1477526400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1681171200000",
    "number": "1982156766",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "700 BROADWAY",
            "city": "SEATTLE",
            "state": "WA",
            "postal_code": "981224302",
            "telephone_number": "206-720-3734",
            "fax_number": "206-292-2163"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "939 CAROLINE ST",
            "city": "PORT ANGELES",
            "state": "WA",
            "postal_code": "983623997",
            "telephone_number": "360-417-7125",
            "fax_number": "360-417-7188"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "MARY",
        "middle_name": "TERESE",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2016-10-27",
        "last_updated": "2023-04-11",
        "certification_date": "2023-04-05",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "133V00000X",
            "taxonomy_group": "",
            "desc": "Dietitian, Registered",
            "state": "WA",
            "license": "DI 60685427",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "TERESE",
            "last_name": "WALLACE",
            "credential": "RDN",
            "code": "2",
            "type": "Professional Name"
        }
    ]
}

• Walgreen Co
• Danyelle J Walker, DDS
• Justin Ford Walker
• Michael Walker
• Caron Elizabeth Wallace, CDPT
• Emily Marie Wallen, DO
• Dianna L Waller, P.T.
• Steven E Walls, FNP
• Walmart Inc.
• Jonathan Lee Walsch

• Registered Dietitian in Port Angeles, WA
• Providers in Port Angeles, WA by specialty
• Registered Dietitian in Washington

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 11, 2023; 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.