Healthcare Provider Details

I. General information

NPI: 1871458448
Provider Name (Legal Business Name): CHARLOTTE GRACE MALLON KOLADA WHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2025
Last Update Date: 12/17/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 IRVING ST APT 2
BOSTON MA
02114-3815
US

IV. Provider business mailing address

17 IRVING ST APT 2
BOSTON MA
02114-3815
US

V. Phone/Fax

Practice location:
  • Phone: 847-650-9801
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberRN2355993
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: