Provider Demographics
NPI:1891022828
Name:WALLACE, LETICIA KRISTIN (RD,LD)
Entity type:Individual
Prefix:
First Name:LETICIA
Middle Name:KRISTIN
Last Name:WALLACE
Suffix:
Gender:
Credentials:RD,LD
Other - Prefix:
Other - First Name:LETICIA
Other - Middle Name:W
Other - Last Name:MCLEOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD,LD
Mailing Address - Street 1:1111 E CESAR CHAVEZ ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78702-4209
Mailing Address - Country:US
Mailing Address - Phone:512-978-8130
Mailing Address - Fax:
Practice Address - Street 1:211 COMAL ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78702-4326
Practice Address - Country:US
Practice Address - Phone:512-978-8130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-12
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT80777133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8V5795OtherBCBS
TX207207601Medicaid