Healthcare Provider Details

I. General information

NPI: 1245833805
Provider Name (Legal Business Name): KEMEALO DIANE MOUSSATCHA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2020
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 PLEASANT ST
MALDEN MA
02148-3087
US

IV. Provider business mailing address

75 PLEASANT ST
MALDEN MA
02148-3087
US

V. Phone/Fax

Practice location:
  • Phone: 617-756-8310
  • Fax: 781-605-0528
Mailing address:
  • Phone: 617-756-8310
  • Fax: 781-605-0528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN2302863
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: