Provider Demographics
NPI:1568525921
Name:BALANTIC, KATHLEEN M (APRN)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:BALANTIC
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 EASTERN POINT RD
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-4905
Mailing Address - Country:US
Mailing Address - Phone:860-833-9390
Mailing Address - Fax:
Practice Address - Street 1:75 EASTERN POINT RD
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-4905
Practice Address - Country:US
Practice Address - Phone:860-833-9390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6429363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004190302Medicaid
CT050001247CT01OtherANTHEM BLUE CROSS
350000991Medicare ID - Type Unspecified
CT004190302Medicaid