| Doctor Name: | SUSAN ELIZABETH WALLACE |
| NPI Number: | 1376842732 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | R,D., L.D. |
| License Number: | KY-1998 |
| Business Practice Address: | 102 Carran Dr Lakeside Park, KY - 410172233 |
| Business Phone Number: | 8593312939 |
| Business Fax Number: | |
| Mailing Address: | 102 Carran Dr, LAKESIDE PARK |
| State: | KY |
| Postal Code: | 410172233 |
| Phone Number: | 8593312939 |
| Fax Number: | |
| NPI Enumeration Date: | 03/23/2011 |
| NPI Last Update Date: | 03/23/2011 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 133V00000X |
| License Number: | KY-1998 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | KY |
| Taxonomy Type: | Dietary & Nutritional Service Providers |
| Taxonomy Classification: | Dietitian, Registered |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A registered dietician (RD) is a food and nutrition expert who has successfully completed a minimum of a bachelor |