Provider Demographics
NPI:1154535318
Name:STICKNEY, CAROLYN A (MD)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:A
Last Name:STICKNEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 LONGWOOD AVE, LO 011
Mailing Address - Street 2:MEDICINE CRITICAL CARE CHILDREN'S HOSPITAL BOSTON
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-5724
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:333 LONGWOOD AVE, LO 011
Practice Address - Street 2:CRITICAL CARE MEDICINE, BOSTON CHILDREN'S HOSPITAL
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5724
Practice Address - Country:US
Practice Address - Phone:617-355-4480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57.009030207R00000X, 208000000X
MA2400532080P0203X
OH35-0913622080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9959153OtherAETNA
OH2839192Medicaid
OH2839192Medicaid