Provider Demographics
NPI:1275918286
Name:FALLAVOLLITA, KATHRYN (PA)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:FALLAVOLLITA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DEPT 3010, PO BOX 986524
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02298-6524
Mailing Address - Country:US
Mailing Address - Phone:401-443-4992
Mailing Address - Fax:401-537-7241
Practice Address - Street 1:375 WAMPANOAG TRL
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:RI
Practice Address - Zip Code:02915-2232
Practice Address - Country:US
Practice Address - Phone:401-649-4070
Practice Address - Fax:401-649-4071
Is Sole Proprietor?:No
Enumeration Date:2015-07-21
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3383363A00000X
MAPA5430363A00000X
RIPA01569363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant