Provider Demographics
NPI:1831320092
Name:WENTZELL, KATHERINE (PNP)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:WENTZELL
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:WENTZELL
Other - Last Name:MITCHELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PNP
Mailing Address - Street 1:1 JOSLIN PL
Mailing Address - Street 2:PEDIATRICS
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-5306
Mailing Address - Country:US
Mailing Address - Phone:617-732-2603
Mailing Address - Fax:617-309-2451
Practice Address - Street 1:1 JOSLIN PL
Practice Address - Street 2:PEDIATRICS
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-5306
Practice Address - Country:US
Practice Address - Phone:617-732-2603
Practice Address - Fax:617-309-2451
Is Sole Proprietor?:No
Enumeration Date:2009-08-05
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA284349163W00000X
MARN284349363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1320858OtherGROUP MEDICAID NUMBER