Healthcare Provider Details

I. General information

NPI: 1992294219
Provider Name (Legal Business Name): KATHRYN RYAN KINGMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2018
Last Update Date: 11/03/2020
Certification Date: 11/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

780 ALBANY ST
BOSTON MA
02118-2755
US

IV. Provider business mailing address

780 ALBANY ST
BOSTON MA
02118-2755
US

V. Phone/Fax

Practice location:
  • Phone: 857-654-1000
  • Fax:
Mailing address:
  • Phone: 857-654-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN2299675
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License NumberRN2299675
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberRN2299675
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: