Provider Demographics
NPI:1306350517
Name:KELLY-KNIGHT, KADIAN RENNYA
Entity type:Individual
Prefix:
First Name:KADIAN
Middle Name:RENNYA
Last Name:KELLY-KNIGHT
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 1:42 WOODROW AVE
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124-3238
Mailing Address - Country:US
Mailing Address - Phone:617-297-6908
Mailing Address - Fax:
Practice Address - Street 1:217 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:WINTHROP
Practice Address - State:MA
Practice Address - Zip Code:02152-3012
Practice Address - Country:US
Practice Address - Phone:617-846-7676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-27
Last Update Date:2017-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALN92561164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse