=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225875610
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHERINE KELLEY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2024
-----------------------------------------------------
Last Update Date | 12/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 52 STILES RD STE 110
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03079-4879
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-685-4609
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6 MARTIN LOUIS WAY
-----------------------------------------------------
City | STONEHAM
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02180-4233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-507-1874
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 116243-23
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------