Healthcare Provider Details

I. General information

NPI: 1295352821
Provider Name (Legal Business Name): NICOLE LYNN KILEY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2020
Last Update Date: 08/04/2020
Certification Date: 08/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 HARRISON AVE
BOSTON MA
02118-2905
US

IV. Provider business mailing address

801 ALBANY ST FL G
BOSTON MA
02119-3791
US

V. Phone/Fax

Practice location:
  • Phone: 617-638-6610
  • Fax: 617-638-6616
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA7570
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: