Healthcare Provider Details

I. General information

NPI: 1902089014
Provider Name (Legal Business Name): STACEY L GALVIN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2007
Last Update Date: 12/12/2023
Certification Date: 12/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

199 REEDSDALE RD
MILTON MA
02186-3926
US

IV. Provider business mailing address

330 BROOKLINE AVE
BOSTON MA
02215-5400
US

V. Phone/Fax

Practice location:
  • Phone: 617-667-3110
  • Fax: 617-754-8791
Mailing address:
  • Phone: 617-667-3110
  • Fax: 617-754-8791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number235410
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number235410
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: