Provider Demographics
NPI:1568662492
Name:WALLIS, KRISTEN S (MD)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:S
Last Name:WALLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:299 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06518-3026
Mailing Address - Country:US
Mailing Address - Phone:203-288-4288
Mailing Address - Fax:203-288-1566
Practice Address - Street 1:299 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-3026
Practice Address - Country:US
Practice Address - Phone:203-288-4288
Practice Address - Fax:855-414-4010
Is Sole Proprietor?:No
Enumeration Date:2007-07-19
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY244100208000000X
CT046513208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT02896880Medicaid