Provider Demographics
NPI:1760855936
Name:VISWANATH, KELLEY ELIZABETH (ARNP)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:ELIZABETH
Last Name:VISWANATH
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:KELLEY
Other - Middle Name:ELIZABETH
Other - Last Name:STARKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:77 POND AVE APARTMENT 1109
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445
Mailing Address - Country:US
Mailing Address - Phone:651-278-2390
Mailing Address - Fax:
Practice Address - Street 1:85 HIGH ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155
Practice Address - Country:US
Practice Address - Phone:781-396-4770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-09
Last Update Date:2017-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9389209363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily