Provider Demographics
NPI:1932585957
Name:WALL, CALLAN E (RD, LDN)
Entity type:Individual
Prefix:
First Name:CALLAN
Middle Name:E
Last Name:WALL
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7507
Mailing Address - Country:US
Mailing Address - Phone:910-239-3562
Mailing Address - Fax:877-889-2993
Practice Address - Street 1:5405 CAROLYN DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28409-5913
Practice Address - Country:US
Practice Address - Phone:919-244-8234
Practice Address - Fax:877-889-2993
Is Sole Proprietor?:No
Enumeration Date:2015-07-31
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133V00000X
NCL004679133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
86056016OtherCDR