Provider Demographics
NPI:1447479985
Name:POULAKOS, EKATERINI (APRN,BC)
Entity type:Individual
Prefix:
First Name:EKATERINI
Middle Name:
Last Name:POULAKOS
Suffix:
Gender:F
Credentials:APRN,BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 ASHLAND ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-3214
Mailing Address - Country:US
Mailing Address - Phone:781-395-3870
Mailing Address - Fax:
Practice Address - Street 1:180 MORTON ST
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-3735
Practice Address - Country:US
Practice Address - Phone:617-626-9558
Practice Address - Fax:617-626-9591
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA142122364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult