Provider Demographics
NPI:1083300271
Name:FLAHERTY, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:FLAHERTY
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 1:20 DAVENPORT RD
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-1608
Mailing Address - Country:US
Mailing Address - Phone:508-641-9077
Mailing Address - Fax:
Practice Address - Street 1:20 DAVENPORT RD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-1608
Practice Address - Country:US
Practice Address - Phone:508-641-9077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-12
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2347962208000000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse