Provider Demographics
NPI:1962146696
Name:WALLACE, ALEXA NICOLE (MS, RD, LD)
Entity type:Individual
Prefix:
First Name:ALEXA
Middle Name:NICOLE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:LEXI
Other - Middle Name:
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS, RD, LD
Mailing Address - Street 1:6600 S YALE AVE STE 1200
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3333
Mailing Address - Country:US
Mailing Address - Phone:918-488-6653
Mailing Address - Fax:918-488-6098
Practice Address - Street 1:6160 S YALE AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-1900
Practice Address - Country:US
Practice Address - Phone:918-497-3140
Practice Address - Fax:918-499-3295
Is Sole Proprietor?:No
Enumeration Date:2022-04-27
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2528133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered