Provider Demographics
NPI:1346997343
Name:SLACK, KATHLEEN MARIE (RN, MSN, PMHNP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARIE
Last Name:SLACK
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Gender:F
Credentials:RN, MSN, PMHNP
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Mailing Address - Street 1:39 BARTON RD
Mailing Address - Street 2:
Mailing Address - City:FOXBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:02035-2838
Mailing Address - Country:US
Mailing Address - Phone:508-596-6720
Mailing Address - Fax:
Practice Address - Street 1:155 SOUTH STREET
Practice Address - Street 2:STE 101
Practice Address - City:WRENTHAM
Practice Address - State:MA
Practice Address - Zip Code:02093-2838
Practice Address - Country:US
Practice Address - Phone:508-964-3330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-09
Last Update Date:2023-07-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA197713363LP0808X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse