Provider Demographics
NPI:1477867455
Name:LAVINE, KELLEY (APRN)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:LAVINE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:KELLEY
Other - Middle Name:
Other - Last Name:MOCKUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RNP
Mailing Address - Street 1:PO BOX 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:800-225-8885
Mailing Address - Fax:508-334-1977
Practice Address - Street 1:119 BELMONT ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-2903
Practice Address - Country:US
Practice Address - Phone:508-334-6206
Practice Address - Fax:508-334-6083
Is Sole Proprietor?:No
Enumeration Date:2010-08-02
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN246110363L00000X, 363LN0005X
RIAPRN01247363LN0000X
RICNPP37216363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110127839AMedicaid