Provider Demographics
NPI:1407088024
Name:VENIOS, KIKI CONSTANCE
Entity Type:Individual
Prefix:MS
First Name:KIKI
Middle Name:CONSTANCE
Last Name:VENIOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 MASSACHUSETTS AVE
Mailing Address - Street 2:FL 2
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 BOSTON MEDICAL CTR PL
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2908
Practice Address - Country:US
Practice Address - Phone:617-414-4505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-14
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN280987363LP0808X
CA19227363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110101725AMedicaid