Provider Demographics
NPI:1639423882
Name:WALLINGTON, CARMEN LEE
Entity Type:Individual
Prefix:MRS
First Name:CARMEN
Middle Name:LEE
Last Name:WALLINGTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 W ALEXANDRINE ST
Mailing Address - Street 2:SUITE 3810
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2015
Mailing Address - Country:US
Mailing Address - Phone:313-446-8880
Mailing Address - Fax:313-446-8889
Practice Address - Street 1:79 W ALEXANDRINE ST
Practice Address - Street 2:SUITE 3810
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2015
Practice Address - Country:US
Practice Address - Phone:313-446-8880
Practice Address - Fax:313-446-8889
Is Sole Proprietor?:No
Enumeration Date:2012-11-08
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704278833163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse