Provider Demographics
NPI:1194789644
Name:KIMBALL-WREN, PAULETTE R (MD)
Entity type:Individual
Prefix:DR
First Name:PAULETTE
Middle Name:R
Last Name:KIMBALL-WREN
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 1:22 QUAIL RUN
Mailing Address - Street 2:
Mailing Address - City:HOLDEN
Mailing Address - State:MA
Mailing Address - Zip Code:01520-3705
Mailing Address - Country:US
Mailing Address - Phone:508-829-3076
Mailing Address - Fax:
Practice Address - Street 1:10 WINTHROP ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01604-4435
Practice Address - Country:US
Practice Address - Phone:508-753-3120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2011-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA224655208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA468484OtherTUFTS
MA7555668OtherAETNA
MA967630OtherNETWORK HEALTH
MAAA37548OtherHARVARD PILGRIM
MAJ29116OtherBLUE CROSS/BLUE SHIELD
MA2000302001OtherCIGNA
MA2105608Medicaid
MA96080OtherFALLON