Healthcare Provider Details

I. General information

NPI: 1689050056
Provider Name (Legal Business Name): KATHLEEN MARY CIVIELLO R.N
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2015
Last Update Date: 08/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

398 NEPONSET AVE
DORCHESTER MA
02122-3134
US

IV. Provider business mailing address

1135 MORTON ST
MATTAPAN MA
02126-2834
US

V. Phone/Fax

Practice location:
  • Phone: 617-533-2269
  • Fax:
Mailing address:
  • Phone: 617-533-2269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN263050
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: