Provider Demographics
NPI:1962791616
Name:KELLEHER-YASSEN, DONNA B (CCRN, FNP-C)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:B
Last Name:KELLEHER-YASSEN
Suffix:
Gender:F
Credentials:CCRN, FNP-C
Other - Prefix:
Other - First Name:DONNA
Other - Middle Name:BERNADETTE
Other - Last Name:MATTHIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:720 HARRISON AVE
Mailing Address - Street 2:DOB 503
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:732 HARRISON AVE
Practice Address - Street 2:PRESTON, 2ND FLOOR
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2309
Practice Address - Country:US
Practice Address - Phone:617-638-7470
Practice Address - Fax:617-638-7449
Is Sole Proprietor?:No
Enumeration Date:2011-04-04
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN237160363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110089218AMedicaid
MA002213701Medicare PIN