Provider Demographics
NPI:1881177921
Name:BIRKHOLZ, KATHERINE DELLE (CNP)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:DELLE
Last Name:BIRKHOLZ
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:LOUISE
Other - Last Name:DELLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:PO BOX 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:800-225-8885
Mailing Address - Fax:
Practice Address - Street 1:55 LAKE AVE N
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:774-441-8082
Practice Address - Fax:774-441-8056
Is Sole Proprietor?:No
Enumeration Date:2018-09-14
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2307980363LP0200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110148050AMedicaid