Provider Demographics
NPI:1528505476
Name:ISHAC, KRISTIN J (NP-C)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:J
Last Name:ISHAC
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 BROOKLINE AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-3904
Mailing Address - Country:US
Mailing Address - Phone:617-421-2686
Mailing Address - Fax:
Practice Address - Street 1:133 BROOKLINE AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-3904
Practice Address - Country:US
Practice Address - Phone:617-421-2686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-30
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN212307363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily