Provider Demographics
NPI:1619493376
Name:FUCILLO, KELLY NELIGAN (PA-C, MPAS)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:NELIGAN
Last Name:FUCILLO
Suffix:
Gender:F
Credentials:PA-C, MPAS
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ELIZABETH
Other - Last Name:NELIGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:270 BOWDOIN ST
Mailing Address - Street 2:
Mailing Address - City:WINTHROP
Mailing Address - State:MA
Mailing Address - Zip Code:02152-1735
Mailing Address - Country:US
Mailing Address - Phone:516-528-7927
Mailing Address - Fax:
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2621
Practice Address - Country:US
Practice Address - Phone:617-724-2844
Practice Address - Fax:617-726-5804
Is Sole Proprietor?:No
Enumeration Date:2017-08-15
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA6259363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant