Healthcare Provider Details

I. General information

NPI: 1568297521
Provider Name (Legal Business Name): NIKA VALENTINE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2024
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 HUNTINGTON AVE
BOSTON MA
02115-5000
US

IV. Provider business mailing address

PO BOX 24520
NEW YORK NY
10087-3720
US

V. Phone/Fax

Practice location:
  • Phone: 617-373-3195
  • Fax:
Mailing address:
  • Phone: 781-744-8085
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA102056
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: