Provider Demographics
NPI:1841990462
Name:KISOB, MAURINE AZA
Entity type:Individual
Prefix:
First Name:MAURINE
Middle Name:AZA
Last Name:KISOB
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 1:100 CONCORD ST STE 2A&B
Mailing Address - Street 2:
Mailing Address - City:FRAMINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01702-8328
Mailing Address - Country:US
Mailing Address - Phone:508-817-5041
Mailing Address - Fax:
Practice Address - Street 1:100 CONCORD ST STE 2A&B
Practice Address - Street 2:
Practice Address - City:FRAMINGHAM
Practice Address - State:MA
Practice Address - Zip Code:01702-8328
Practice Address - Country:US
Practice Address - Phone:508-817-5041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-03
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2290966163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health