Individual
SUSAN ELIZABETH WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
R,D., L.D.
Contact information
Practice address
102 CARRAN DR, LAKESIDE PARK, KY 41017-2233
(859) 331-2939
Mailing address
102 CARRAN DR, LAKESIDE PARK, KY 41017-2233
(859) 331-2939
Taxonomy
Speciality
Code
Description
License number
State
133V00000X
Registered Dietitian
Primary
KY-1998
KY
Other
Enumeration date
03/23/2011
Last updated
03/23/2011
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