Provider Demographics
NPI:1710969589
Name:DERMADY, KATHLEEN M (CNM)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:DERMADY
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:
Other - Last Name:MCMAHON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:800-225-8885
Mailing Address - Fax:508-334-1977
Practice Address - Street 1:119 BELMONT ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-2903
Practice Address - Country:US
Practice Address - Phone:508-334-0550
Practice Address - Fax:508-334-8496
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN133233367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03054804Medicaid
NYJ400016216Medicare PIN