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General NPI Number Information
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NPI Number | 1760119648
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Entity Type | Individual
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Provider Name | KETMA PERICLES
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Gender | Female
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Dates
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Enumeration Date | 08/02/2022
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Last Update Date | 08/02/2022
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Provider Practice Location Address
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Address Line | 1493 CAMBRIDGE ST
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City | CAMBRIDGE
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State | MA
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Zip | 02139-1047
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Country | US
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Telephone | 781-397-6546
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Fax |
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Provider Business Mailing Address
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Address Line | 36 TEA PARTY WAY
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City | MALDEN
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State | MA
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Zip | 02148-1980
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Country | US
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Telephone | 781-922-1097
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 164W00000X
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Taxonomy Name | Licensed Practical Nurse
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License Number | LN69424
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License Number State | MA
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