Provider Demographics
NPI:1467483230
Name:KOVACH, JOAN STACK (APRN, BC)
Entity type:Individual
Prefix:
First Name:JOAN
Middle Name:STACK
Last Name:KOVACH
Suffix:
Gender:F
Credentials:APRN, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 MILL ST
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:MA
Mailing Address - Zip Code:02478-1041
Mailing Address - Country:US
Mailing Address - Phone:508-894-8316
Mailing Address - Fax:508-894-8334
Practice Address - Street 1:MCLEAN HOSPITAL SOUTHEAST LOCATION
Practice Address - Street 2:940 BELMONT STREET
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301
Practice Address - Country:US
Practice Address - Phone:508-894-8316
Practice Address - Fax:508-894-8334
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA111881364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPN0237OtherBCBS
MAPN0237OtherBCBS