Healthcare Provider Details

I. General information

NPI: 1679349211
Provider Name (Legal Business Name): SIOBHAN ELIZABETH KELLY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/27/2023
Last Update Date: 02/25/2026
Certification Date: 02/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT STREET
BOSTON MA
02241-9095
US

IV. Provider business mailing address

128 BUNKER HILL ST
CHARLESTOWN MA
02129-3128
US

V. Phone/Fax

Practice location:
  • Phone: 617-726-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN2340465
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberRN2340465
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License NumberRN2340465
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: