1518233931 NPI number — PROF. LEAH GYNELL WALLACE PA-C

Table of content: PROF. LEAH GYNELL WALLACE PA-C (NPI 1518233931)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518233931 NPI number — PROF. LEAH GYNELL WALLACE PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLACE
Provider First Name:
LEAH
Provider Middle Name:
GYNELL
Provider Name Prefix Text:
PROF.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
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:
1518233931
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/25/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
28 CRESCENT ST
Provider Second Line Business Mailing Address:
SUITE 106
Provider Business Mailing Address City Name:
MIDDLETOWN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06457-3654
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-358-4820
Provider Business Mailing Address Fax Number:
860-358-8661

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1347 BOSTON POST RD
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
MADISON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06443-3475
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-779-5207
Provider Business Practice Location Address Fax Number:
203-779-5792
Provider Enumeration Date:
03/29/2012

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: 363A00000X , with the licence number:  002731 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 008039969 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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