Provider Demographics
NPI:1124241104
Name:WALD, LEONORE KRISTINE (PA-C)
Entity type:Individual
Prefix:MS
First Name:LEONORE
Middle Name:KRISTINE
Last Name:WALD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 WALCOTT RD
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-2343
Mailing Address - Country:US
Mailing Address - Phone:978-969-5998
Mailing Address - Fax:
Practice Address - Street 1:36 WALCOTT RD
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-2343
Practice Address - Country:US
Practice Address - Phone:978-969-5998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1630363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant