Provider Demographics
NPI:1548498595
Name:GRADY, NICOLE ERIN GALES
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ERIN GALES
Last Name:GRADY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:ERIN
Other - Last Name:GALES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:330 MOUNT AUBURN ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-5502
Mailing Address - Country:US
Mailing Address - Phone:617-499-5595
Mailing Address - Fax:617-499-5103
Practice Address - Street 1:330 MOUNT AUBURN ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-5502
Practice Address - Country:US
Practice Address - Phone:617-499-5595
Practice Address - Fax:617-499-5103
Is Sole Proprietor?:No
Enumeration Date:2009-06-29
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA241241208000000X
IL0361320902080N0001X
MA2509892080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics