Individual
DONNA M WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
ARPN
Contact information
Practice address
46 ALBION ST, BRIDGEPORT, CT 06605-2602
(203) 330-6000
(203) 330-6007
Mailing address
46 ALBION ST, SOUTHWEST COMMUNITY HEALTH CENTER, INC, BRIDGEPORT, CT 06605-2602
(203) 332-3155
(203) 330-6008
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
Primary
003840
CT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
003840
STATE LICENSE 003840
CT
05
—
004236130
—
CT
Enumeration date
08/12/2008
Last updated
08/22/2014
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