Provider Demographics
NPI:1801048921
Name:O'BRIEN, KATIE BROUILLARD (NP)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:BROUILLARD
Last Name:O'BRIEN
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 1:36 ADAMS STREET
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169
Mailing Address - Country:US
Mailing Address - Phone:617-773-0711
Mailing Address - Fax:617-376-2271
Practice Address - Street 1:36 ADAMS STREET
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169
Practice Address - Country:US
Practice Address - Phone:617-773-9805
Practice Address - Fax:617-472-5400
Is Sole Proprietor?:No
Enumeration Date:2008-10-21
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA284603207N00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner