Healthcare Provider Details

I. General information

NPI: 1972507325
Provider Name (Legal Business Name): MARY KATHLEEN SMITH NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 01/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

780 ALBANY ST
BOSTON MA
02118-2524
US

IV. Provider business mailing address

780 ALBANY ST
BOSTON MA
02118-2524
US

V. Phone/Fax

Practice location:
  • Phone: 857-654-1000
  • Fax: 857-654-1100
Mailing address:
  • Phone: 857-654-1000
  • Fax: 857-654-1100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209862
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: