Provider Demographics
NPI:1083711972
Name:KELLY, KATHRYN BURKE (APRN-BC)
Entity Type:Individual
Prefix:MS
First Name:KATHRYN
Middle Name:BURKE
Last Name:KELLY
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 1:324 PURCHASE ST
Mailing Address - Street 2:SUITE 12B
Mailing Address - City:SOUTH EASTON
Mailing Address - State:MA
Mailing Address - Zip Code:02375-1641
Mailing Address - Country:US
Mailing Address - Phone:508-297-2316
Mailing Address - Fax:508-297-1712
Practice Address - Street 1:324 PURCHASE ST
Practice Address - Street 2:SUITE 12B
Practice Address - City:SOUTH EASTON
Practice Address - State:MA
Practice Address - Zip Code:02375-1641
Practice Address - Country:US
Practice Address - Phone:508-297-2316
Practice Address - Fax:508-297-1712
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA85454 PC364SP0808X, 364SP0810X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
No364SP0810XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Child & Family
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPN0357OtherBLUE CROSS BLUE SHIELD
MAPN0357OtherBLUE CROSS BLUE SHIELD