Provider Demographics
NPI:1326303629
Name:CARNEY, KATELYN ROSE (NP)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:ROSE
Last Name:CARNEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KATELYN
Other - Middle Name:ROSE
Other - Last Name:DERBY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:44 SHORE DR
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:NH
Mailing Address - Zip Code:03079-1337
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:950 WINTER ST STE 3800
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-1405
Practice Address - Country:US
Practice Address - Phone:781-779-5172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-12
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN277452363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110093599AMedicaid
MA002787701Medicare PIN