Healthcare Provider Details

I. General information

NPI: 1275918286
Provider Name (Legal Business Name): KATHRYN FALLAVOLLITA PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2015
Last Update Date: 07/10/2023
Certification Date: 07/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 WAMPANOAG TRL
RIVERSIDE RI
02915-2232
US

IV. Provider business mailing address

DEPT 3010, PO BOX 986524
BOSTON MA
02298-6524
US

V. Phone/Fax

Practice location:
  • Phone: 401-649-4070
  • Fax: 401-649-4071
Mailing address:
  • Phone: 401-443-4992
  • Fax: 401-537-7241

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3383
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA5430
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA01569
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: