Provider Demographics
NPI:1235663089
Name:VITTUM, KERRY ANA (CRNA)
Entity type:Individual
Prefix:
First Name:KERRY
Middle Name:ANA
Last Name:VITTUM
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KERRY
Other - Middle Name:ANA
Other - Last Name:MCGEOGHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:163 LIBBEY PKWY STE 301
Mailing Address - Street 2:
Mailing Address - City:WEYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02189-3118
Mailing Address - Country:US
Mailing Address - Phone:781-337-4224
Mailing Address - Fax:781-335-0429
Practice Address - Street 1:55 FOGG RD
Practice Address - Street 2:
Practice Address - City:SOUTH WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02190
Practice Address - Country:US
Practice Address - Phone:781-624-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-19
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN268888367500000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse