Healthcare Provider Details

I. General information

NPI: 1154638260
Provider Name (Legal Business Name): MARY ELLEN KISTLER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2010
Last Update Date: 01/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MONTVALE AVE STE 502
STONEHAM MA
02180-3559
US

IV. Provider business mailing address

1 MONTVALE AVE STE 502
STONEHAM MA
02180-3559
US

V. Phone/Fax

Practice location:
  • Phone: 781-279-0971
  • Fax: 617-573-5646
Mailing address:
  • Phone: 781-279-0971
  • Fax: 617-573-5646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1545
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: