Provider Demographics
NPI:1629046644
Name:WALL-HAAS, CONSTANCE L (DNP)
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:L
Last Name:WALL-HAAS
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 MILK ST
Mailing Address - Street 2:PROVIDER ENROLLMENT - 9TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-4806
Mailing Address - Country:US
Mailing Address - Phone:617-559-8053
Mailing Address - Fax:978-250-6335
Practice Address - Street 1:228 BILLERICA RD
Practice Address - Street 2:
Practice Address - City:CHELMSFORD
Practice Address - State:MA
Practice Address - Zip Code:01824-3604
Practice Address - Country:US
Practice Address - Phone:978-250-6000
Practice Address - Fax:978-250-6335
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA126600363L00000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0359891Medicaid
MANP9996OtherBLUE CROSS
MANP1803Medicare ID - Type Unspecified
MA0359891Medicaid