=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164113791
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISTEN LEIGH KLIMM PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2023
-----------------------------------------------------
Last Update Date | 05/16/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2 DUDLEY ST STE 190
-----------------------------------------------------
City | PROVIDENCE
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02905-3248
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-421-1939
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 43 SOLEY ST APT 2
-----------------------------------------------------
City | CHARLESTOWN
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02129-3310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 774-487-2493
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | PA01588
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------