Provider Demographics
NPI:1164517504
Name:BALLENTINE, KATHLEEN ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ANN
Last Name:BALLENTINE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1182
Mailing Address - Street 2:141 TEN ROD RD
Mailing Address - City:ROCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03866-1182
Mailing Address - Country:US
Mailing Address - Phone:603-332-4828
Mailing Address - Fax:603-332-2165
Practice Address - Street 1:333 BORTHWICK AVE, SUITE 301
Practice Address - Street 2:KNEES, HOPS, SHOULDERS
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801
Practice Address - Country:US
Practice Address - Phone:603-431-5858
Practice Address - Fax:603-332-2165
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2010-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0543P363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical