Healthcare Provider Details

I. General information

NPI: 1568662492
Provider Name (Legal Business Name): KRISTEN S WALLIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2007
Last Update Date: 04/30/2021
Certification Date: 04/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

299 WASHINGTON AVE
HAMDEN CT
06518-3026
US

IV. Provider business mailing address

299 WASHINGTON AVE
HAMDEN CT
06518-3026
US

V. Phone/Fax

Practice location:
  • Phone: 203-288-4288
  • Fax: 855-414-4010
Mailing address:
  • Phone: 203-288-4288
  • Fax: 203-288-1566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number244100
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number046513
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: