Provider Demographics
NPI:1952703092
Name:WALLACE, KATIE LYNN (FNP-BC)
Entity Type:Individual
Prefix:MS
First Name:KATIE
Middle Name:LYNN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 MALL RD
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01805-0002
Mailing Address - Country:US
Mailing Address - Phone:781-744-8085
Mailing Address - Fax:
Practice Address - Street 1:67 S BEDFORD ST STE 101E
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01803-5152
Practice Address - Country:US
Practice Address - Phone:781-744-8085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-19
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2275454363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily