Provider Demographics
NPI:1962145284
Name:ETTINGER, CHELSEA RENEE
Entity type:Individual
Prefix:
First Name:CHELSEA
Middle Name:RENEE
Last Name:ETTINGER
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 1:55 FRUIT STREET, WHITE 1
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-6241
Mailing Address - Country:US
Mailing Address - Phone:617-724-4100
Mailing Address - Fax:617-726-7415
Practice Address - Street 1:55 FRUIT STREET, WHITE 1
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-6241
Practice Address - Country:US
Practice Address - Phone:617-724-4100
Practice Address - Fax:617-726-7415
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-14
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-2259363A00000X
MAPA9506363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant