Provider Demographics
NPI:1316129455
Name:FALLON, KATHRYN ANN (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ANN
Last Name:FALLON
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 ASCOT LN
Mailing Address - Street 2:
Mailing Address - City:OLD LYME
Mailing Address - State:CT
Mailing Address - Zip Code:06371-1870
Mailing Address - Country:US
Mailing Address - Phone:860-434-1008
Mailing Address - Fax:
Practice Address - Street 1:8 ASCOT LN
Practice Address - Street 2:
Practice Address - City:OLD LYME
Practice Address - State:CT
Practice Address - Zip Code:06371-1870
Practice Address - Country:US
Practice Address - Phone:860-434-1008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-30
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002085363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily