Healthcare Provider Details

I. General information

NPI: 1023592896
Provider Name (Legal Business Name): TYLER ANNE KOLVATZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2018
Last Update Date: 09/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

780 ALBANY ST
BOSTON MA
02118-2755
US

IV. Provider business mailing address

5 DAWES TER APT 2
DORCHESTER MA
02125-1720
US

V. Phone/Fax

Practice location:
  • Phone: 857-654-1000
  • Fax: 857-654-1100
Mailing address:
  • Phone: 617-894-0443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberRN2312117
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: