Provider Demographics
NPI:1861418535
Name:WALLACE, LEE S (MS, RD, LDN, FADA)
Entity type:Individual
Prefix:MS
First Name:LEE
Middle Name:S
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MS, RD, LDN, FADA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38105-5003
Mailing Address - Country:US
Mailing Address - Phone:901-448-6511
Mailing Address - Fax:901-448-7097
Practice Address - Street 1:711 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38105-5003
Practice Address - Country:US
Practice Address - Phone:901-448-6511
Practice Address - Fax:901-448-7097
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLDN0000000356133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic