Provider Demographics
NPI:1275796740
Name:PROVOST, KIRA E (RN, LCMT)
Entity Type:Individual
Prefix:MS
First Name:KIRA
Middle Name:E
Last Name:PROVOST
Suffix:
Gender:F
Credentials:RN, LCMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 WHITMAN ST
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:RI
Mailing Address - Zip Code:02917-3813
Mailing Address - Country:US
Mailing Address - Phone:401-486-6951
Mailing Address - Fax:
Practice Address - Street 1:1145 RESERVOIR AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02920-6055
Practice Address - Country:US
Practice Address - Phone:401-943-2500
Practice Address - Fax:401-942-2227
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-05
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRN26228163W00000X
RIMT01762225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist