Provider Demographics
NPI:1205974250
Name:HEALEY, KIRSTEN M
Entity type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:M
Last Name:HEALEY
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 1:811 AQUIDNECK AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02842-5256
Mailing Address - Country:US
Mailing Address - Phone:401-849-0190
Mailing Address - Fax:401-849-3986
Practice Address - Street 1:811 AQUIDNECK AVE
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:RI
Practice Address - Zip Code:02842-5256
Practice Address - Country:US
Practice Address - Phone:401-849-0190
Practice Address - Fax:401-849-3986
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIODT00478152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI419021531Medicare ID - Type Unspecified
U79279Medicare UPIN