Provider Demographics
NPI:1235374414
Name:KIKUCHI, ITOKO (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:ITOKO
Middle Name:
Last Name:KIKUCHI
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 NEPONSET AVE
Mailing Address - Street 2:FL 3
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02122
Mailing Address - Country:US
Mailing Address - Phone:857-217-3700
Mailing Address - Fax:
Practice Address - Street 1:415 NEPONSET AVE
Practice Address - Street 2:FL 3
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02122
Practice Address - Country:US
Practice Address - Phone:857-217-3700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-02
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
MARN2292722363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No251S00000XAgenciesCommunity/Behavioral Health