Healthcare Provider Details

I. General information

NPI: 1225126832
Provider Name (Legal Business Name): CAROL ANNE O'LEARY APRN, PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 02/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 N BEACON ST
WATERTOWN MA
02472-2751
US

IV. Provider business mailing address

175 N BEACON ST
WATERTOWN MA
02472-2751
US

V. Phone/Fax

Practice location:
  • Phone: 617-972-7290
  • Fax: 617-972-7345
Mailing address:
  • Phone: 617-972-7290
  • Fax: 617-972-7345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number178285
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number178285
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: