Provider Demographics
NPI:1063865780
Name:WALLIS, KRISTEN (RN)
Entity Type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:
Last Name:WALLIS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7199 CREECH RD
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13045-8901
Mailing Address - Country:US
Mailing Address - Phone:607-749-3208
Mailing Address - Fax:
Practice Address - Street 1:7199 CREECH RD
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:NY
Practice Address - Zip Code:13045-8901
Practice Address - Country:US
Practice Address - Phone:607-749-3208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-18
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY671965-1163W00000X, 163WC0400X, 163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WH0200XNursing Service ProvidersRegistered NurseHome Health