Healthcare Provider Details

I. General information

NPI: 1073061883
Provider Name (Legal Business Name): KETTELYNE GILLES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2016
Last Update Date: 10/26/2022
Certification Date: 10/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CUMMINGS CENTER SUITE 344F
BEVERLY MA
01915
US

IV. Provider business mailing address

460 MYSTIC AVE UNIT 402
SOMERVILLE MA
02145-1721
US

V. Phone/Fax

Practice location:
  • Phone: 857-415-6439
  • Fax: 888-776-1247
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License NumberRN2286201
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: