Provider Demographics
NPI:1356104962
Name:AXTEN, KATHERINE
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:AXTEN
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 1:765 E 3RD ST STE 201
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02127-2336
Mailing Address - Country:US
Mailing Address - Phone:781-249-6647
Mailing Address - Fax:
Practice Address - Street 1:765 E 3RD ST STE 201
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02127-2336
Practice Address - Country:US
Practice Address - Phone:781-249-6647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2372143163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health