Provider Demographics
NPI:1881660561
Name:OCALLAGHAN, KIMBERLY ANN (NP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:OCALLAGHAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545A CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-2061
Mailing Address - Country:US
Mailing Address - Phone:617-477-4929
Mailing Address - Fax:617-522-0903
Practice Address - Street 1:545A CENTRE ST
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-2061
Practice Address - Country:US
Practice Address - Phone:617-477-4929
Practice Address - Fax:617-522-0903
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA167499363LA2200X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0321451Medicaid
NP0604OtherBLUE SHIELD
83-01261OtherEVERCARE
P00456876OtherRAILROAD MEDICARE
P00456876OtherRAILROAD MEDICARE
MA0321451Medicaid
VX0287Medicare PIN