Healthcare Provider Details

I. General information

NPI: 1306240429
Provider Name (Legal Business Name): KIMBERLY REARDON BANIGAN CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2014
Last Update Date: 08/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LONGWOOD AVE
BOSTON MA
02115-5724
US

IV. Provider business mailing address

300 LONGWOOD AVE
BOSTON MA
02115
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-6162
  • Fax: 617-730-0621
Mailing address:
  • Phone: 617-355-6162
  • Fax: 617-730-0621

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number209011064
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberRN2316271
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: