Healthcare Provider Details

I. General information

NPI: 1962145284
Provider Name (Legal Business Name): CHELSEA RENEE ETTINGER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2022
Last Update Date: 01/16/2024
Certification Date: 01/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT STREET, WHITE 1
BOSTON MA
02114-6241
US

IV. Provider business mailing address

55 FRUIT STREET, WHITE 1
BOSTON MA
02114-6241
US

V. Phone/Fax

Practice location:
  • Phone: 617-724-4100
  • Fax: 617-726-7415
Mailing address:
  • Phone: 617-724-4100
  • Fax: 617-726-7415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-2259
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9506
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: