Provider Demographics
NPI:1184958480
Name:FOGARTY, KATE VITT (MSN)
Entity type:Individual
Prefix:
First Name:KATE
Middle Name:VITT
Last Name:FOGARTY
Suffix:
Gender:F
Credentials:MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-2230
Mailing Address - Country:US
Mailing Address - Phone:603-512-1044
Mailing Address - Fax:
Practice Address - Street 1:23 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01901-1220
Practice Address - Country:US
Practice Address - Phone:781-581-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-21
Last Update Date:2009-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN280420364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health