Healthcare Provider Details

I. General information

NPI: 1699754861
Provider Name (Legal Business Name): JUDITH SMITH CASEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2006
Last Update Date: 04/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 WARREN ST
BRIGHTON MA
02135-3601
US

IV. Provider business mailing address

77 WARREN ST
BRIGHTON MA
02135-3601
US

V. Phone/Fax

Practice location:
  • Phone: 617-562-5250
  • Fax: 617-562-5277
Mailing address:
  • Phone: 617-562-5250
  • Fax: 617-562-5277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number152507
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: