Healthcare Provider Details

I. General information

NPI: 1063192755
Provider Name (Legal Business Name): KATHERINE WASSERMAN FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2023
Last Update Date: 03/17/2026
Certification Date: 03/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ONE GATEWAY CENTER SUITE 2600
NEWARK NJ
07102-5323
US

IV. Provider business mailing address

109 STATE STREET 5TH FL
BOSTON MA
02109-2906
US

V. Phone/Fax

Practice location:
  • Phone: 617-505-1520
  • Fax: 617-928-8401
Mailing address:
  • Phone: 617-505-1520
  • Fax: 617-928-8401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ14879500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: