Healthcare Provider Details

I. General information

NPI: 1346881000
Provider Name (Legal Business Name): MR. SAMUEL KEATING HARRELL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2019
Last Update Date: 07/16/2025
Certification Date: 07/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

624 WAVERLEY ST
FRAMINGHAM MA
01702-6981
US

IV. Provider business mailing address

30 ARDALE ST
ROSLINDALE MA
02131-1506
US

V. Phone/Fax

Practice location:
  • Phone: 508-504-1955
  • Fax:
Mailing address:
  • Phone: 301-602-0198
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberRN2319853
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN2319853
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number354434
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: