Healthcare Provider Details

I. General information

NPI: 1023583689
Provider Name (Legal Business Name): KATHERINE MARIE HANTKE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2018
Last Update Date: 01/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST
BOSTON MA
02114-2696
US

IV. Provider business mailing address

2117 HILLCREST DR
VENTURA CA
93001-2411
US

V. Phone/Fax

Practice location:
  • Phone: 617-726-8218
  • Fax:
Mailing address:
  • Phone: 805-746-0075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number798964
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number95000995
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN2329625
License Number StateMA
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN2329625
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: