Provider Demographics
NPI:1578684411
Name:WALLMAN, CAROLYN ANN (APRN)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:ANN
Last Name:WALLMAN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 GARLAND ST
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:MA
Mailing Address - Zip Code:02149-5066
Mailing Address - Country:US
Mailing Address - Phone:617-797-4267
Mailing Address - Fax:
Practice Address - Street 1:103 GARLAND ST
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:MA
Practice Address - Zip Code:02149-5066
Practice Address - Country:US
Practice Address - Phone:617-797-4267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA164236363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110076801AMedicaid
MAWANP1602OtherBCBS
MA500030719OtherMEDICARE RAIL ROAD
MAS72844OtherUPIN
MA110076801AMedicaid
MAUX9263Medicare PIN