Provider Demographics
NPI:1528579257
Name:DEVEJIAN, KATHLEEN NELLIE (CNP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:NELLIE
Last Name:DEVEJIAN
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 MARSTON ST APT 202
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01841-2357
Mailing Address - Country:US
Mailing Address - Phone:978-946-8550
Mailing Address - Fax:978-946-8010
Practice Address - Street 1:25 MARSTON ST APT 202
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01841-2357
Practice Address - Country:US
Practice Address - Phone:978-946-8550
Practice Address - Fax:978-946-8010
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-20
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN203026363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty