Provider Demographics
NPI:1093809378
Name:WALLACE, ANN XAVIER (NPC APRN BC)
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:XAVIER
Last Name:WALLACE
Suffix:
Gender:F
Credentials:NPC APRN BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:586 PLAIN ST
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02072
Mailing Address - Country:US
Mailing Address - Phone:781-341-1149
Mailing Address - Fax:
Practice Address - Street 1:71 WALNUT ST
Practice Address - Street 2:
Practice Address - City:FOXBORO
Practice Address - State:MA
Practice Address - Zip Code:02035
Practice Address - Country:US
Practice Address - Phone:781-341-1149
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA122528363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Not Answered363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P21944Medicare UPIN
MAWANP2968Medicare ID - Type Unspecified