Healthcare Provider Details

I. General information

NPI: 1932772704
Provider Name (Legal Business Name): KELLY MARIE WULFF FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2021
Last Update Date: 12/16/2021
Certification Date: 12/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

732 HARRISON AVE FL PRESTON3
BOSTON MA
02118-2309
US

IV. Provider business mailing address

801 ALBANY ST FL G
BOSTON MA
02119-3791
US

V. Phone/Fax

Practice location:
  • Phone: 617-638-7490
  • Fax: 617-414-8742
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN2301322
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: