Individual
MRS. ELLEN EASLEY WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
CDE, RD, LD
Contact information
Practice address
103 STARR AVE APT 66, STARKVILLE, MS 39759-4058
(662) 418-1184
Mailing address
PO BOX 5333, MISSISSIPPI STATE, MS 39762-5333
(662) 418-1184
Taxonomy
Speciality
Code
Description
License number
State
133V00000X
Registered Dietitian
Primary
D1317
MS
Other
Enumeration date
05/10/2011
Last updated
05/10/2011
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