Individual
PROF. LEAH GYNELL WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
1347 BOSTON POST RD, SUITE 106, MADISON, CT 06443-3475
(203) 779-5207
(203) 779-5792
Mailing address
28 CRESCENT ST, SUITE 106, MIDDLETOWN, CT 06457-3654
(860) 358-4820
(860) 358-8661
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
002731
CT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
008039969
—
CT
Enumeration date
03/29/2012
Last updated
02/25/2015
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