Provider Demographics
NPI:1578194627
Name:SPALLA, KATHLEEN ANNE (PNP)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:ANNE
Last Name:SPALLA
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:ANNE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:194 ELMWOOD RD
Mailing Address - Street 2:
Mailing Address - City:NEEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02492-4546
Mailing Address - Country:US
Mailing Address - Phone:781-400-5800
Mailing Address - Fax:
Practice Address - Street 1:194 ELMWOOD RD
Practice Address - Street 2:
Practice Address - City:NEEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02492-4546
Practice Address - Country:US
Practice Address - Phone:781-400-5800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN237611363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics