Basic Information
| Provider Information | |||||||||
| NPI: | 1235663089 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VITTUM | ||||||||
| FirstName: | KERRY | ||||||||
| MiddleName: | ANA | ||||||||
| NamePrefix: | |||||||||
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| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCGEOGHAN | ||||||||
| OtherFirstName: | KERRY | ||||||||
| OtherMiddleName: | ANA | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | CRNA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 163 LIBBEY PKWY STE 301 | ||||||||
| Address2: | |||||||||
| City: | WEYMOUTH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021893118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7813374224 | ||||||||
| FaxNumber: | 7813350429 | ||||||||
| Practice Location | |||||||||
| Address1: | 55 FOGG RD | ||||||||
| Address2: | |||||||||
| City: | SOUTH WEYMOUTH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7816248000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2017 | ||||||||
| LastUpdateDate: | 09/06/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN268888 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 163W00000X | RN268888 | MA | N | Nursing Service Providers | Registered Nurse |
No ID Information.