Healthcare Provider Details

I. General information

NPI: 1962010371
Provider Name (Legal Business Name): KETIA GERALDE ELISCAR CATIN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2020
Last Update Date: 12/18/2022
Certification Date: 12/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58 CHARLES ST
CAMBRIDGE MA
02141-2128
US

IV. Provider business mailing address

235 WELLESLEY ST
WESTON MA
02493-1572
US

V. Phone/Fax

Practice location:
  • Phone: 617-953-1387
  • Fax:
Mailing address:
  • Phone: 617-953-1387
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberRN2258980
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF11220920
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: