Healthcare Provider Details

I. General information

NPI: 1407159247
Provider Name (Legal Business Name): KATHRYN DELACK NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHRYN O'BRIEN

II. Dates (important events)

Enumeration Date: 12/17/2010
Last Update Date: 04/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST
BOSTON MA
02114-2621
US

IV. Provider business mailing address

18 RIVERWOOD DR
MANSFIELD MA
02048-1775
US

V. Phone/Fax

Practice location:
  • Phone: 617-726-2000
  • Fax:
Mailing address:
  • Phone: 617-212-5318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License NumberNPP37591
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN273564
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: