1740409143 NPI number — CATHERINE B WALL PNP-BC

Table of content: CATHERINE B WALL PNP-BC (NPI 1740409143)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740409143 NPI number — CATHERINE B WALL PNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALL
Provider First Name:
CATHERINE
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1740409143
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/28/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
450 BROOKLINE AVE
Provider Second Line Business Mailing Address:
DANA 3
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02215-5418
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-632-5464
Provider Business Mailing Address Fax Number:
617-582-8350

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
450 BROOKLINE AVE
Provider Second Line Business Practice Location Address:
DANA 3
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02215
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-632-5464
Provider Business Practice Location Address Fax Number:
617-582-8350
Provider Enumeration Date:
04/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0200X , with the licence number:  F381877-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0200X , with the licence number: RN270714 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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