Healthcare Provider Details

I. General information

NPI: 1508010638
Provider Name (Legal Business Name): KATHLEEN WALLACE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2008
Last Update Date: 11/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LONGWOOD AVE
BOSTON MA
02115-5724
US

IV. Provider business mailing address

244 BUNKER HILL STREET
CHARLESTOWN MA
02129
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-8117
  • Fax:
Mailing address:
  • Phone: 617-512-5297
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number258192
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: