Provider Demographics
NPI:1851523278
Name:WALSH, KATHRYN MARY (ANP-BC)
Entity Type:Individual
Prefix:MS
First Name:KATHRYN
Middle Name:MARY
Last Name:WALSH
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:523 OLD BOONTON RD
Mailing Address - Street 2:
Mailing Address - City:BOONTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07005-2071
Mailing Address - Country:US
Mailing Address - Phone:973-462-6340
Mailing Address - Fax:
Practice Address - Street 1:523 OLD BOONTON RD
Practice Address - Street 2:
Practice Address - City:BOONTON
Practice Address - State:NJ
Practice Address - Zip Code:07005-2071
Practice Address - Country:US
Practice Address - Phone:973-462-6340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-18
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY304928363LA2200X
NJ26NJ00191000363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0250147Medicaid
NJ800576A02Medicare PIN