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NPI Code Detail

MEDICARE: MRS. KRISTAN MARIE BOUTWELL RN, CPNP

MEDICARE: MRS. KRISTAN MARIE BOUTWELL RN, CPNP
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363LP0200XPediatric Nurse PractitionerRN259832MA

General Provider Information

NPI Number : 1801174529
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. KRISTAN MARIE BOUTWELL RN, CPNP
Provider Business Mailing Address
First Line : 300 LONGWOOD AVE
Second Line : MAIN BUILDING, 7 NORTH NICU
City : BOSTON
State : MA
Zip : 02115-5724
Country : US
Telephone Number : 617-355-8076
Fax Number : 617-730-0902
Provider Business Practice Location Address
First Line : 300 LONGWOOD AVE
Second Line : MAIN BUILDING, 7 NORTH NICU
City : BOSTON
State : MA
Zip : 02115-5724
Country : US
Telephone Number : 617-355-8076
Fax Number : 617-730-0902
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/29/2011
Last Update Date : 07/29/2011

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