=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144346537
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CYNTHIA MCKALLAGAT CFM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 349 N MAIN ST
-----------------------------------------------------
City | ANDOVER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01810-2687
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-475-7779
-----------------------------------------------------
Fax | 978-475-1662
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 39 FERNWOOD AVE
-----------------------------------------------------
City | HAVERHILL
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01835-8153
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-521-1492
-----------------------------------------------------
Fax | 978-475-1662
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | CFM01485
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------