Provider Demographics
NPI:1477540250
Name:PACK, KATHRYN (ARNP)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:PACK
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164 SUMMIT AVE
Mailing Address - Street 2:CARDIOLOGY NP OFFICE 4TH FLOOR
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-2853
Mailing Address - Country:US
Mailing Address - Phone:401-793-2500
Mailing Address - Fax:401-793-3141
Practice Address - Street 1:164 SUMMIT AVE
Practice Address - Street 2:CARDIOLOGY NP OFFICE 4TH FLOOR
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-2853
Practice Address - Country:US
Practice Address - Phone:401-793-2500
Practice Address - Fax:401-793-3141
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2019-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RINPP37363363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200001260AMedicaid
OK248302401Medicare ID - Type Unspecified
OK200001260AMedicaid