Basic Information
| Provider Information | |||||||||
| NPI: | 1942400916 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALL | ||||||||
| FirstName: | KAREN | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2110 SILAS DEANE HWY | ||||||||
| Address2: | 2ND FL | ||||||||
| City: | ROCKY HILL | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060672313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602583470 | ||||||||
| FaxNumber: | 8605716800 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 RETREAT AVE | ||||||||
| Address2: | SUITE 605 | ||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061062528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602440148 | ||||||||
| FaxNumber: | 8602407067 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2007 | ||||||||
| LastUpdateDate: | 07/25/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 003632 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2100X | 003632 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 003632 | 01 | CT | MEDICAL LICENSE | OTHER |