=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790237469
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIM A CONNOLLY NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2016
-----------------------------------------------------
Last Update Date | 02/04/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 162 CORDAVILLE RD
-----------------------------------------------------
City | SOUTHBOROUGH
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01772-1838
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-229-8811
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 67 UNION ST FL 2 CHILD DEVELOPMENT UNIT
-----------------------------------------------------
City | NATICK
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01760-6089
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-650-7733
-----------------------------------------------------
Fax | 508-650-7807
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number | RN155278
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------