Healthcare Provider Details

I. General information

NPI: 1710054713
Provider Name (Legal Business Name): KELLY M. CICCONE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY M. WILLIAMS PA-C

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 10/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

LAHEY CLINIC 41 MALL RD
BURLINGTON MA
01805-0001
US

IV. Provider business mailing address

LAHEY CLINIC 41 MALL RD
BURLINGTON MA
01805-0001
US

V. Phone/Fax

Practice location:
  • Phone: 781-744-8886
  • Fax: 781-744-2956
Mailing address:
  • Phone: 781-744-8886
  • Fax: 781-744-2956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2035
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: