Provider Demographics
NPI:1225126832
Name:O'LEARY, CAROL ANNE (APRN, PNP)
Entity Type:Individual
Prefix:
First Name:CAROL ANNE
Middle Name:
Last Name:O'LEARY
Suffix:
Gender:F
Credentials:APRN, PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 N BEACON ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-2751
Mailing Address - Country:US
Mailing Address - Phone:617-972-7290
Mailing Address - Fax:617-972-7345
Practice Address - Street 1:175 N BEACON ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-2751
Practice Address - Country:US
Practice Address - Phone:617-972-7290
Practice Address - Fax:617-972-7345
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA178285163W00000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0713589Medicaid
MA0713589Medicaid
MANP2492Medicare PIN