Provider Demographics
NPI:1205807179
Name:WALLACE, KERI ANN (MD)
Entity type:Individual
Prefix:DR
First Name:KERI
Middle Name:ANN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KERI
Other - Middle Name:ANN
Other - Last Name:LINDELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:282 WASHINGTON ST
Mailing Address - Street 2:CCMC, PRIMARY CARE CENTER, 1F
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-3322
Mailing Address - Country:US
Mailing Address - Phone:860-545-9333
Mailing Address - Fax:860-545-9301
Practice Address - Street 1:282 WASHINGTON ST
Practice Address - Street 2:CCMC, PRIMARY CARE CENTER, 1F
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-3322
Practice Address - Country:US
Practice Address - Phone:860-545-9333
Practice Address - Fax:860-545-9301
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT046025208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics