Healthcare Provider Details

I. General information

NPI: 1114821618
Provider Name (Legal Business Name): KATHERINE C WALLACE APRN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2026
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 JONES HOLLOW RD
MARLBOROUGH CT
06447-1448
US

IV. Provider business mailing address

14 JONES HOLLOW RD
MARLBOROUGH CT
06447-1448
US

V. Phone/Fax

Practice location:
  • Phone: 860-295-8217
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number18417
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: