Healthcare Provider Details

I. General information

NPI: 1033040670
Provider Name (Legal Business Name): KIRA WOLLENSAK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2026
Last Update Date: 05/25/2026
Certification Date: 05/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

147 MASON TER
BROOKLINE MA
02446-2781
US

IV. Provider business mailing address

147 MASON TER APT 1
BROOKLINE MA
02446-2781
US

V. Phone/Fax

Practice location:
  • Phone: 802-595-5144
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN2380561
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: