Healthcare Provider Details

I. General information

NPI: 1235379090
Provider Name (Legal Business Name): JENNIFER M WALLACE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2009
Last Update Date: 04/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3640 MAIN ST SUITE 302
SPRINGFIELD MA
01107-1145
US

IV. Provider business mailing address

3640 MAIN ST SUITE 302
SPRINGFIELD MA
01107-1145
US

V. Phone/Fax

Practice location:
  • Phone: 413-732-4242
  • Fax: 413-732-4040
Mailing address:
  • Phone: 413-732-4242
  • Fax: 413-732-4040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN218174
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: