Provider Demographics
NPI:1336822253
Name:BELLEGARDE, KATISHA ERMITE
Entity Type:Individual
Prefix:
First Name:KATISHA
Middle Name:ERMITE
Last Name:BELLEGARDE
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 1:55 FRUIT ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2621
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2621
Practice Address - Country:US
Practice Address - Phone:617-726-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-08
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2331508363L00000X, 163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice