Provider Demographics
NPI:1932734886
Name:WALLACE, KATHERINE ABIGAIL (RN)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ABIGAIL
Last Name:WALLACE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 COTTAGE ST
Mailing Address - Street 2:
Mailing Address - City:MILBRIDGE
Mailing Address - State:ME
Mailing Address - Zip Code:04658-3534
Mailing Address - Country:US
Mailing Address - Phone:207-598-6064
Mailing Address - Fax:
Practice Address - Street 1:43 COTTAGE ST
Practice Address - Street 2:
Practice Address - City:MILBRIDGE
Practice Address - State:ME
Practice Address - Zip Code:04658-3534
Practice Address - Country:US
Practice Address - Phone:207-598-6064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-10
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MERN66836163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse