Provider Demographics
NPI:1821007782
Name:PRUCNAL, KATHLEEN A (OD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:A
Last Name:PRUCNAL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 MAIN STREET,
Mailing Address - Street 2:#106
Mailing Address - City:TOWNSEND
Mailing Address - State:MA
Mailing Address - Zip Code:01469
Mailing Address - Country:US
Mailing Address - Phone:978-597-5227
Mailing Address - Fax:978-597-5700
Practice Address - Street 1:18 MAIN STREET,
Practice Address - Street 2:#106
Practice Address - City:TOWNSEND
Practice Address - State:MA
Practice Address - Zip Code:01469
Practice Address - Country:US
Practice Address - Phone:978-597-5227
Practice Address - Fax:978-597-5700
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2842152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0356719Medicaid
MA0356719Medicaid