Provider Demographics
NPI:1619557881
Name:BALLA, BLERTA (RN AGNP)
Entity Type:Individual
Prefix:
First Name:BLERTA
Middle Name:
Last Name:BALLA
Suffix:
Gender:F
Credentials:RN AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WINTHROP
Mailing Address - State:MA
Mailing Address - Zip Code:02152-3142
Mailing Address - Country:US
Mailing Address - Phone:617-938-7802
Mailing Address - Fax:
Practice Address - Street 1:29 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WINTHROP
Practice Address - State:MA
Practice Address - Zip Code:02152-3142
Practice Address - Country:US
Practice Address - Phone:617-938-7802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-12
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2269491363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner