Healthcare Provider Details

I. General information

NPI: 1982522314
Provider Name (Legal Business Name): PAIGE VIVIAN WALLAT APRN, CPNP-PC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 BEACON ST APT 1D
BROOKLINE MA
02446-3973
US

IV. Provider business mailing address

1110 BEACON ST APT 1D
BROOKLINE MA
02446-3973
US

V. Phone/Fax

Practice location:
  • Phone: 603-714-5986
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberRN2379084
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: