Basic Information
| Provider Information | |||||||||
| NPI: | 1578836219 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHAMPION | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MPAS, PA-C | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | CHAMPION | ||||||||
| OtherFirstName: | KELLY | ||||||||
| OtherMiddleName: | NICOLE | ||||||||
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| OtherCredential: | MPAS, PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 26 FRANKFORT ST # 3 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021283114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9786978726 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 199 REEDSDALE RD | ||||||||
| Address2: | |||||||||
| City: | MILTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021863926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176964600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2012 | ||||||||
| LastUpdateDate: | 04/10/2018 | ||||||||
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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 | 363A00000X | PA4354 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.