Provider Demographics
NPI:1295352821
Name:KILEY, NICOLE LYNN (PA-C)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYNN
Last Name:KILEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 ALBANY ST FL G
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02119-3791
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:840 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2905
Practice Address - Country:US
Practice Address - Phone:617-638-6610
Practice Address - Fax:617-638-6616
Is Sole Proprietor?:No
Enumeration Date:2020-06-30
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA7570363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant