Healthcare Provider Details

I. General information

NPI: 1619557881
Provider Name (Legal Business Name): BLERTA BALLA RN AGNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2021
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST
BOSTON MA
02114-2621
US

IV. Provider business mailing address

29 S MAIN ST
WINTHROP MA
02152-3142
US

V. Phone/Fax

Practice location:
  • Phone: 617-726-1002
  • Fax:
Mailing address:
  • Phone: 617-938-7802
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN2269491
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: