Provider Demographics
NPI:1548870710
Name:HEFFERNAN, KATHLEEN (APN)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:HEFFERNAN
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:258 MAIN ST STE B1
Mailing Address - Street 2:
Mailing Address - City:BOURNE
Mailing Address - State:MA
Mailing Address - Zip Code:02532-3251
Mailing Address - Country:US
Mailing Address - Phone:508-317-5900
Mailing Address - Fax:
Practice Address - Street 1:258 MAIN ST STE B1
Practice Address - Street 2:
Practice Address - City:BOURNE
Practice Address - State:MA
Practice Address - Zip Code:02532-3251
Practice Address - Country:US
Practice Address - Phone:857-263-3758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-03
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN143164163W00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse