Healthcare Provider Details

I. General information

NPI: 1083378269
Provider Name (Legal Business Name): KETTA PIERRE GERMAIN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2021
Last Update Date: 10/25/2021
Certification Date: 10/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 POOLE ST
BROCKTON MA
02301-1803
US

IV. Provider business mailing address

51 POOLE ST
BROCKTON MA
02301-1803
US

V. Phone/Fax

Practice location:
  • Phone: 617-818-4751
  • Fax:
Mailing address:
  • Phone: 617-818-4751
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberRN2262346
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: