Provider Demographics
NPI:1578146791
Name:KIZHAKKEDATH, ANEESH K (NP)
Entity Type:Individual
Prefix:
First Name:ANEESH
Middle Name:K
Last Name:KIZHAKKEDATH
Suffix:
Gender:M
Credentials:NP
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2 BANCROFT ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01887-2544
Mailing Address - Country:US
Mailing Address - Phone:857-919-2364
Mailing Address - Fax:
Practice Address - Street 1:1 DEACONESS RD
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-5321
Practice Address - Country:US
Practice Address - Phone:617-754-3180
Practice Address - Fax:617-754-3184
Is Sole Proprietor?:No
Enumeration Date:2021-05-05
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA266779363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health