Healthcare Provider Details

I. General information

NPI: 1013355981
Provider Name (Legal Business Name): KELLY ANN DOUGHERTY CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2013
Last Update Date: 06/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST GRB 444
BOSTON MA
02114-2621
US

IV. Provider business mailing address

95 WALDEMAR AVE
WINTHROP MA
02152-2346
US

V. Phone/Fax

Practice location:
  • Phone: 617-461-8029
  • Fax:
Mailing address:
  • Phone: 617-461-8029
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN237716
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: