Provider Demographics
NPI:1477156222
Name:LATRAVERSE, KATHLEEN
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:LATRAVERSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 KNOWLTON CIR
Mailing Address - Street 2:
Mailing Address - City:UPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01568-1491
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 MILLISTON RD
Practice Address - Street 2:
Practice Address - City:MILLIS
Practice Address - State:MA
Practice Address - Zip Code:02054-1600
Practice Address - Country:US
Practice Address - Phone:508-376-2975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH235231183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist