Provider Demographics
NPI:1164010682
Name:ROUSSEAU, KEVIN WILLIAM
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:WILLIAM
Last Name:ROUSSEAU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:MILLIS
Mailing Address - State:MA
Mailing Address - Zip Code:02054-1477
Mailing Address - Country:US
Mailing Address - Phone:774-249-8782
Mailing Address - Fax:
Practice Address - Street 1:69 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:MILLIS
Practice Address - State:MA
Practice Address - Zip Code:02054-1477
Practice Address - Country:US
Practice Address - Phone:774-249-8782
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-10
Last Update Date:2021-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA146044163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice