Provider Demographics
NPI:1184301509
Name:SCANLON, KATHERINE G (CNS)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:G
Last Name:SCANLON
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1042 RANDOLPH AVE
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:MA
Mailing Address - Zip Code:02186-5838
Mailing Address - Country:US
Mailing Address - Phone:617-721-0057
Mailing Address - Fax:
Practice Address - Street 1:771 ALBANY ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2525
Practice Address - Country:US
Practice Address - Phone:617-638-2825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-28
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN270043364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist