Provider Demographics
NPI:1154130177
Name:CANN, KELLIE
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:CANN
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 1:59 NORFOLK ST
Mailing Address - Street 2:
Mailing Address - City:NEEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02492-3227
Mailing Address - Country:US
Mailing Address - Phone:617-835-0144
Mailing Address - Fax:
Practice Address - Street 1:59 NORFOLK ST
Practice Address - Street 2:
Practice Address - City:NEEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02492-3227
Practice Address - Country:US
Practice Address - Phone:617-835-0144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-03
Last Update Date:2025-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2345044163WP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent