Individual
MS. AMA GEAN WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
RD
Contact information
Practice address
2200 FORT ROOTS DR, NORTH LITTLE ROCK, AR 72114-1709
(501) 257-2017
(501) 257-2026
Mailing address
22 LATOUR, LITTLE ROCK, AR 72223-8904
(501) 257-2017
(501) 257-2026
Taxonomy
Speciality
Code
Description
License number
State
133V00000X
Registered Dietitian
Primary
0257
AR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
R660145
REGISTRATION NUMBER
AR
Enumeration date
09/29/2006
Last updated
07/08/2007
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