Provider Demographics
NPI:1992320212
Name:KELLY, CAITLIN MARIE
Entity type:Individual
Prefix:
First Name:CAITLIN
Middle Name:MARIE
Last Name:KELLY
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 1:1 BROOKLINE PL STE 406
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-7296
Mailing Address - Country:US
Mailing Address - Phone:617-278-8080
Mailing Address - Fax:
Practice Address - Street 1:1 BROOKLINE PL STE 406
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02445-7296
Practice Address - Country:US
Practice Address - Phone:617-278-8000
Practice Address - Fax:617-754-8634
Is Sole Proprietor?:No
Enumeration Date:2020-06-12
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2304227208VP0000X
MAF02200556363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine