Healthcare Provider Details

I. General information

NPI: 1588200042
Provider Name (Legal Business Name): KRISTIN L. KOO CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTIN LEE KOO CNM

II. Dates (important events)

Enumeration Date: 11/20/2019
Last Update Date: 04/11/2024
Certification Date: 04/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 HARRISON AVE, FL 4 YAWKEY BLDG
BOSTON MA
02118
US

IV. Provider business mailing address

960 MASSACHUSETTS AVE FL 2
BOSTON MA
02118-2690
US

V. Phone/Fax

Practice location:
  • Phone: 617-414-2000
  • Fax: 617-414-5798
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number26NR20043600
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number25ME00070100
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberRN2362061
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: