Provider Demographics
NPI:1689183014
Name:POULLIOT, KRISTY (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:KRISTY
Middle Name:
Last Name:POULLIOT
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:MISS
Other - First Name:KRISTY
Other - Middle Name:
Other - Last Name:POOLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
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 1:55 LAKE AVE N
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:508-334-2731
Practice Address - Fax:774-442-4672
Is Sole Proprietor?:No
Enumeration Date:2017-09-28
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7330363LF0000X
MARN2268086363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily