Healthcare Provider Details

I. General information

NPI: 1013427970
Provider Name (Legal Business Name): MICHELLE KENNY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2017
Last Update Date: 10/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

529 MAIN ST STE 216
CHARLESTOWN MA
02129-1122
US

IV. Provider business mailing address

30 WINTER ST FL 9
BOSTON MA
02108-4720
US

V. Phone/Fax

Practice location:
  • Phone: 617-426-0600
  • Fax:
Mailing address:
  • Phone: 617-426-0600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberRN2261585
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: