Healthcare Provider Details

I. General information

NPI: 1952302267
Provider Name (Legal Business Name): ELLEN DIANNE KAWADLER APRN, BC, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: ELLEN DIANNE KNOFF

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1071 BLUE HILL AVE
MILTON MA
02186-2302
US

IV. Provider business mailing address

64 FURNACE ST
SHARON MA
02067-2808
US

V. Phone/Fax

Practice location:
  • Phone: 617-333-2394
  • Fax: 617-333-2029
Mailing address:
  • Phone: 781-784-7807
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number137476
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: