Healthcare Provider Details

I. General information

NPI: 1396254470
Provider Name (Legal Business Name): KAITLIN BOULEY MS, CNP, AGNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KAITLIN CHESNULEVICH BS, RN

II. Dates (important events)

Enumeration Date: 09/21/2017
Last Update Date: 09/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 SYLVAN ST STE B102
DANVERS MA
01923-2764
US

IV. Provider business mailing address

471 OSGOOD RD
MILFORD NH
03055-3436
US

V. Phone/Fax

Practice location:
  • Phone: 888-283-1722
  • Fax: 978-774-4389
Mailing address:
  • Phone: 603-718-5936
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberRN271153
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: