Provider Demographics
NPI:1215411749
Name:ST BERNARD, KELLY ANNE (NP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANNE
Last Name:ST BERNARD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ANNE
Other - Last Name:MALOY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:41 MONTVALE AVE
Mailing Address - Street 2:
Mailing Address - City:STONEHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02180-2445
Mailing Address - Country:US
Mailing Address - Phone:781-224-5806
Mailing Address - Fax:781-224-5807
Practice Address - Street 1:41 MONTVALE AVE
Practice Address - Street 2:
Practice Address - City:STONEHAM
Practice Address - State:MA
Practice Address - Zip Code:02180-2445
Practice Address - Country:US
Practice Address - Phone:781-224-5806
Practice Address - Fax:781-224-5807
Is Sole Proprietor?:No
Enumeration Date:2018-09-20
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAF06182220363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily