Provider Demographics
NPI:1891466090
Name:CAPOBIANCO, KELLYJO J
Entity Type:Individual
Prefix:
First Name:KELLYJO
Middle Name:J
Last Name:CAPOBIANCO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 FOUNTAIN ST
Mailing Address - Street 2:
Mailing Address - City:FRAMINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01702-6279
Mailing Address - Country:US
Mailing Address - Phone:508-694-3643
Mailing Address - Fax:
Practice Address - Street 1:63 FOUNTAIN ST
Practice Address - Street 2:
Practice Address - City:FRAMINGHAM
Practice Address - State:MA
Practice Address - Zip Code:01702-6279
Practice Address - Country:US
Practice Address - Phone:508-694-3643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-27
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty