Basic Information
| Provider Information | |||||||||
| NPI: | 1962791616 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLEHER-YASSEN | ||||||||
| FirstName: | DONNA | ||||||||
| MiddleName: | B. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CCRN, FNP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MATTHIS | ||||||||
| OtherFirstName: | DONNA | ||||||||
| OtherMiddleName: | BERNADETTE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 720 HARRISON AVE | ||||||||
| Address2: | DOB 503 | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02118 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 732 HARRISON AVE | ||||||||
| Address2: | PRESTON, 2ND FLOOR | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021182309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176387470 | ||||||||
| FaxNumber: | 6176387449 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2011 | ||||||||
| LastUpdateDate: | 06/11/2014 | ||||||||
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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 | 363L00000X | RN237160 | MA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | RN237160 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 110089218A | 05 | MA | MEDICAID |