Provider Demographics
NPI:1518944537
Name:SHEA, KATHLEEN M (NP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:SHEA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH WEYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02190-1561
Mailing Address - Country:US
Mailing Address - Phone:781-340-1702
Mailing Address - Fax:781-340-0931
Practice Address - Street 1:1221 MAIN ST
Practice Address - Street 2:
Practice Address - City:SOUTH WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02190-1561
Practice Address - Country:US
Practice Address - Phone:781-340-1702
Practice Address - Fax:781-340-0931
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA105978363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANP2743OtherBLUE CROSS BLUE SHIELD
MAP15597Medicare UPIN
MANP2743Medicare PIN