Healthcare Provider Details

I. General information

NPI: 1194789644
Provider Name (Legal Business Name): PAULETTE R KIMBALL-WREN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 12/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 WINTHROP ST
WORCESTER MA
01604-4435
US

IV. Provider business mailing address

22 QUAIL RUN
HOLDEN MA
01520-3705
US

V. Phone/Fax

Practice location:
  • Phone: 508-753-3120
  • Fax:
Mailing address:
  • Phone: 508-829-3076
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number224655
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: