Provider Demographics
NPI:1356303820
Name:WALLACE, CHRISTINE LUPA (NP)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:LUPA
Last Name:WALLACE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 RABBIT RD
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01952-1824
Mailing Address - Country:US
Mailing Address - Phone:978-465-2453
Mailing Address - Fax:
Practice Address - Street 1:25 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:NEWBURYPORT
Practice Address - State:MA
Practice Address - Zip Code:01950-3867
Practice Address - Country:US
Practice Address - Phone:978-463-1050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA138593363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANP1484OtherBCBS
MATX4675Medicare PIN
MAS69016Medicare UPIN
MAP00022495Medicare PIN
MANP1484Medicare PIN