Healthcare Provider Details

I. General information

NPI: 1578146791
Provider Name (Legal Business Name): ANEESH K KIZHAKKEDATH NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2021
Last Update Date: 08/24/2021
Certification Date: 05/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 DEACONESS RD
BOSTON MA
02215-5321
US

IV. Provider business mailing address

2 BANCROFT ST
WILMINGTON MA
01887-2544
US

V. Phone/Fax

Practice location:
  • Phone: 617-754-3180
  • Fax: 617-754-3184
Mailing address:
  • Phone: 857-919-2364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number266779
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: