Healthcare Provider Details

I. General information

NPI: 1992320212
Provider Name (Legal Business Name): CAITLIN MARIE KELLY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2020
Last Update Date: 09/18/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BROOKLINE PL STE 406
BROOKLINE MA
02445-7296
US

IV. Provider business mailing address

1 BROOKLINE PL STE 406
BROOKLINE MA
02445-7296
US

V. Phone/Fax

Practice location:
  • Phone: 617-278-8000
  • Fax: 617-754-8634
Mailing address:
  • Phone: 617-278-8080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberRN2304227
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF02200556
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: