Basic Information
| Provider Information | |||||||||
| NPI: | 1780735613 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KETTYLE | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | PRESSLY | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CNM | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 10 GOVE STREET | ||||||||
| Address2: | EAST BOSTON NEIGHBORHOOD HEALTH CENTER | ||||||||
| City: | EAST BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175695800 | ||||||||
| FaxNumber: | 6175684780 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 GOVE STREET | ||||||||
| Address2: | EAST BOSTON NEIGHBORHOOD HEALTH CENTER | ||||||||
| City: | EAST BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175695800 | ||||||||
| FaxNumber: | 6175684780 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2007 | ||||||||
| LastUpdateDate: | 05/17/2016 | ||||||||
| 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 | 367A00000X | RN240561 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 0340570 | 05 | MA | MEDICAID | 1910257-001 | 01 | MA | CIGNA | OTHER | CN0240 | 01 | MA | BCBS | OTHER | 5715344 | 01 | MA | HCVM | OTHER | HV0044 | 01 | MA | HPHC | OTHER |