Provider Demographics
NPI:1598305807
Name:ST MARTIN, KELLIE
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:ST MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:
Other - Last Name:ST MARTIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:415 COLUMBIA RD
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02125-2424
Mailing Address - Country:US
Mailing Address - Phone:617-287-8000
Mailing Address - Fax:
Practice Address - Street 1:415 COLUMBIA RD
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02125-2424
Practice Address - Country:US
Practice Address - Phone:617-287-8000
Practice Address - Fax:617-287-1500
Is Sole Proprietor?:No
Enumeration Date:2020-01-14
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2295376363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health