Provider Demographics
NPI:1053018366
Name:WALLACE, ROBERT BRANDON (RD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:BRANDON
Last Name:WALLACE
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18511 HIGHLANDER MEDICS ST
Mailing Address - Street 2:
Mailing Address - City:FORT BLISS
Mailing Address - State:TX
Mailing Address - Zip Code:79906-5327
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18511 HIGHLANDER MEDICS ST
Practice Address - Street 2:
Practice Address - City:FORT BLISS
Practice Address - State:TX
Practice Address - Zip Code:79906-5327
Practice Address - Country:US
Practice Address - Phone:301-400-3905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-08
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86376928133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered