Basic Information
| Provider Information | |||||||||
| NPI: | 1972989879 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YOUNG | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | SERNYEE | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 296 ESSEX ST | ||||||||
| Address2: | |||||||||
| City: | WEYMOUTH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021884124 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 199 REEDSDALE RD | ||||||||
| Address2: | |||||||||
| City: | MILTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021863926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176964600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2015 | ||||||||
| LastUpdateDate: | 08/03/2015 | ||||||||
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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 | PA5479 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.