Provider Demographics
NPI:1518591619
Name:BLANCHETTE, KELLY A (FNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:BLANCHETTE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 ARSENAL ST APT 489
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-3092
Mailing Address - Country:US
Mailing Address - Phone:978-835-7427
Mailing Address - Fax:
Practice Address - Street 1:204 ARSENAL ST APT 489
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-3092
Practice Address - Country:US
Practice Address - Phone:978-835-7427
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-27
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MARN283893363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program