Provider Demographics
NPI:1720586779
Name:WHITCOMB, KATHLEEN
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:WHITCOMB
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 LAMBERT AVE
Mailing Address - Street 2:
Mailing Address - City:WEYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02189-2667
Mailing Address - Country:US
Mailing Address - Phone:857-719-4684
Mailing Address - Fax:
Practice Address - Street 1:103 MYRON ST STE A
Practice Address - Street 2:
Practice Address - City:WEST SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01089-1485
Practice Address - Country:US
Practice Address - Phone:413-592-1980
Practice Address - Fax:413-439-0100
Is Sole Proprietor?:No
Enumeration Date:2018-01-24
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA000000207Q00000X
MA2314004363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine