Provider Demographics
NPI:1942618061
Name:SHIN, KELLY (NP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SHIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:BRITTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:300 LONGWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-5724
Mailing Address - Country:US
Mailing Address - Phone:617-355-0582
Mailing Address - Fax:617-730-0240
Practice Address - Street 1:300 LONGWOOD AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-5418
Practice Address - Country:US
Practice Address - Phone:617-355-0582
Practice Address - Fax:617-730-0240
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-01
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2272983363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily