Provider Demographics
NPI:1801174529
Name:BOUTWELL, KRISTAN MARIE (RN, CPNP)
Entity type:Individual
Prefix:MRS
First Name:KRISTAN
Middle Name:MARIE
Last Name:BOUTWELL
Suffix:
Gender:F
Credentials:RN, CPNP
Other - Prefix:MS
Other - First Name:KRISTAN
Other - Middle Name:MARIE
Other - Last Name:NATALE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:300 LONGWOOD AVE
Mailing Address - Street 2:MAIN BUILDING, 7 NORTH NICU
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-5724
Mailing Address - Country:US
Mailing Address - Phone:617-355-8076
Mailing Address - Fax:617-730-0902
Practice Address - Street 1:300 LONGWOOD AVE
Practice Address - Street 2:MAIN BUILDING, 7 NORTH NICU
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5724
Practice Address - Country:US
Practice Address - Phone:617-355-8076
Practice Address - Fax:617-730-0902
Is Sole Proprietor?:No
Enumeration Date:2011-07-29
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN259832363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics