Provider Demographics
NPI:1144648510
Name:WALL, COLLEEN ELIZABETH (RD)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:ELIZABETH
Last Name:WALL
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:ELIZABETH
Other - Last Name:SHEMELEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:366 FEDERAL RD
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06804-2406
Mailing Address - Country:US
Mailing Address - Phone:203-775-1819
Mailing Address - Fax:203-775-2028
Practice Address - Street 1:366 FEDERAL RD
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:CT
Practice Address - Zip Code:06804-2406
Practice Address - Country:US
Practice Address - Phone:203-775-1819
Practice Address - Fax:203-775-2028
Is Sole Proprietor?:No
Enumeration Date:2014-04-02
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1188133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered