Basic Information
Provider Information | |||||||||
NPI: | 1700229580 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCA'NULTY | ||||||||
FirstName: | KALEIGH | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 675 PARAMOUNT DR | ||||||||
Address2: |   | ||||||||
City: | RAYNHAM | ||||||||
State: | MA | ||||||||
PostalCode: | 027675416 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5088800012 | ||||||||
FaxNumber: | 5088800032 | ||||||||
Practice Location | |||||||||
Address1: | 22 PROSPECT ST | ||||||||
Address2: |   | ||||||||
City: | NASHUA | ||||||||
State: | NH | ||||||||
PostalCode: | 030603924 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6038831626 | ||||||||
FaxNumber: | 6038819914 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/11/2013 | ||||||||
LastUpdateDate: | 09/04/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA4623 | MA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | 1078 | NH | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
ID | Type | State | Issuer | Description | 3100761 | 05 | NH |   | MEDICAID |