Healthcare Provider Details

I. General information

NPI: 1801262050
Provider Name (Legal Business Name): KATE MYSAK CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2015
Last Update Date: 12/04/2020
Certification Date: 12/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LONGWOOD AVE # FEGAN9
BOSTON MA
02115-5724
US

IV. Provider business mailing address

300 LONGWOOD AVE # FEGAN9
BOSTON MA
02115-5724
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-7970
  • Fax:
Mailing address:
  • Phone: 176-355-7970
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberR186811
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberRN2320642
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: