Healthcare Provider Details

I. General information

NPI: 1609948835
Provider Name (Legal Business Name): KATHLEEN WADDICOR RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 08/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LONGWOOD AVE
BOSTON MA
02115-5724
US

IV. Provider business mailing address

300 LONGWOOD AVENUE
BOSTON MA
02115-2649
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-2966
  • Fax: 617-730-0184
Mailing address:
  • Phone: 617-355-7181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number137308
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: