Provider Demographics
NPI:1376621615
Name:PROULX, KATHRYN A (CNP, PHD)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:A
Last Name:PROULX
Suffix:
Gender:F
Credentials:CNP, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1049 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01103-2114
Mailing Address - Country:US
Mailing Address - Phone:413-739-1100
Mailing Address - Fax:413-304-4666
Practice Address - Street 1:1049 MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01103-2114
Practice Address - Country:US
Practice Address - Phone:413-739-1100
Practice Address - Fax:413-304-4666
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2016-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA127180163WP0808X
CT001162363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110028120Medicaid
MAM21172Medicare UPIN