Provider Demographics
NPI:1740409143
Name:WALL, CATHERINE B (PNP-BC)
Entity Type:Individual
Prefix:
First Name:CATHERINE
Middle Name:B
Last Name:WALL
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Gender:F
Credentials:PNP-BC
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Other - Credentials:
Mailing Address - Street 1:450 BROOKLINE AVE
Mailing Address - Street 2:DANA 3
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-5418
Mailing Address - Country:US
Mailing Address - Phone:617-632-5464
Mailing Address - Fax:617-582-8350
Practice Address - Street 1:450 BROOKLINE AVE
Practice Address - Street 2:DANA 3
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215
Practice Address - Country:US
Practice Address - Phone:617-632-5464
Practice Address - Fax:617-582-8350
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2015-10-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NYF381877-1363LP0200X
MARN270714363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics