Individual
MS. MINDY LEE WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
RD LDN
Contact information
Practice address
935 JERSEY ST, QUINCY, IL 62301-4030
(217) 228-2413
(217) 228-2416
Mailing address
2820 E BLUFF CT, QUINCY, IL 62305-1329
(217) 440-6458
Taxonomy
Speciality
Code
Description
License number
State
133V00000X
Registered Dietitian
Primary
164003636
IL
133V00000X
Registered Dietitian
2005004105
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
00132009
BLUE CROSS BLUE SHIELD IL
IL
01
—
075113
QUINCY HEALTH CARE MANAGE
IL
Enumeration date
07/28/2006
Last updated
09/22/2008
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