Provider Demographics
NPI:1528283694
Name:WATERHOUSE, KATHLEEN (APRN)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:WATERHOUSE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 BEACON ST
Mailing Address - Street 2:HOUSE CALL PROGRAM
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02143-4370
Mailing Address - Country:US
Mailing Address - Phone:617-499-8358
Mailing Address - Fax:
Practice Address - Street 1:120 BEACON ST
Practice Address - Street 2:HOUSE CALL PROGRAM
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02143-4370
Practice Address - Country:US
Practice Address - Phone:617-499-8358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA151684363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANP5210OtherBCBS MA
MANP5210Medicare ID - Type Unspecified
MANP5210OtherBCBS MA