Provider Demographics
NPI:1235962150
Name:YOUNG, KERRY ALISA (RN)
Entity type:Individual
Prefix:
First Name:KERRY
Middle Name:ALISA
Last Name:YOUNG
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:KERRY
Other - Middle Name:ALISA
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:268 W PELHAM RD
Mailing Address - Street 2:
Mailing Address - City:SHUTESBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01072-9704
Mailing Address - Country:US
Mailing Address - Phone:413-658-5782
Mailing Address - Fax:
Practice Address - Street 1:235 GREENFIELD RD
Practice Address - Street 2:
Practice Address - City:SOUTH DEERFIELD
Practice Address - State:MA
Practice Address - Zip Code:01373-9753
Practice Address - Country:US
Practice Address - Phone:413-658-5782
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-26
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2357655163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice