Provider Demographics
NPI:1275784159
Name:PONT, KATHLEEN BLASCAK (NP-BC)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:BLASCAK
Last Name:PONT
Suffix:
Gender:F
Credentials:NP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 WINTER ST
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-1424
Mailing Address - Country:US
Mailing Address - Phone:413-862-4002
Mailing Address - Fax:781-419-8479
Practice Address - Street 1:950 WINTER ST
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-1424
Practice Address - Country:US
Practice Address - Phone:413-862-4002
Practice Address - Fax:781-419-8479
Is Sole Proprietor?:No
Enumeration Date:2008-10-09
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA236539363LA2200X
MARN236539363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health