Basic Information
| Provider Information | |||||||||
| NPI: | 1568718369 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLOSS | ||||||||
| FirstName: | KATHERINE | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SANTORO | ||||||||
| OtherFirstName: | KATHERINE | ||||||||
| OtherMiddleName: | E | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | P.O. BOX 4164 | ||||||||
| Address2: | |||||||||
| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2073237175 | ||||||||
| FaxNumber: | 8668674172 | ||||||||
| Practice Location | |||||||||
| Address1: | 75 CRYSTAL RUN RD | ||||||||
| Address2: | STE 135 | ||||||||
| City: | MIDDLETOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109417009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453337575 | ||||||||
| FaxNumber: | 8453337139 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2012 | ||||||||
| LastUpdateDate: | 02/23/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 617533-1 | NY | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 337559 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 03497972 | 05 | NY | MEDICAID |