Provider Demographics
NPI:1366033102
Name:ALLY IV & THERAPEUTICS, INC
Entity Type:Organization
Organization Name:ALLY IV & THERAPEUTICS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/FOUNDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:SSERUNKUMA
Authorized Official - Last Name:WILKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:617-600-4235
Mailing Address - Street 1:305 NEWBURY ST STE 41
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-2833
Mailing Address - Country:US
Mailing Address - Phone:617-600-4235
Mailing Address - Fax:
Practice Address - Street 1:305 NEWBURY ST STE 41
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-2833
Practice Address - Country:US
Practice Address - Phone:617-600-4235
Practice Address - Fax:617-600-4235
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-02
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty