Provider Demographics
NPI:1366265100
Name:WALLACE, SARA MICHELLE (RD)
Entity type:Individual
Prefix:MRS
First Name:SARA
Middle Name:MICHELLE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:MRS
Other - First Name:SARA
Other - Middle Name:MICHELLE
Other - Last Name:GUY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:26 TWELVE OAKS DR SE
Mailing Address - Street 2:
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30120-5801
Mailing Address - Country:US
Mailing Address - Phone:678-796-5171
Mailing Address - Fax:
Practice Address - Street 1:26 TWELVE OAKS DR SE
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120-5801
Practice Address - Country:US
Practice Address - Phone:678-796-5171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-31
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA86030502133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered