1730797077 NPI number — KRISTIE MICHELLE GRIMES-MALLARD RN

Table of content: KRISTIE MICHELLE GRIMES-MALLARD RN (NPI 1730797077)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730797077 NPI number — KRISTIE MICHELLE GRIMES-MALLARD RN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRIMES-MALLARD
Provider First Name:
KRISTIE
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730797077
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/16/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
34 HOWE ST UNIT 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02125-2143
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-828-9941
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
45 DIMOCK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROXBURY
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02119-1208
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-442-8800
Provider Business Practice Location Address Fax Number:
617-541-8334
Provider Enumeration Date:
07/22/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X , with the licence number:  RN2335640 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: RN2335640 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 110164451A , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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