Provider Demographics
NPI:1447983986
Name:RIDER, KIRSTEN WERNER
Entity type:Individual
Prefix:MRS
First Name:KIRSTEN
Middle Name:WERNER
Last Name:RIDER
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:KIRSTEN
Other - Middle Name:ANN
Other - Last Name:WERNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 LONGWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-5724
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 LONGWOOD AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5724
Practice Address - Country:US
Practice Address - Phone:617-355-8578
Practice Address - Fax:617-734-1034
Is Sole Proprietor?:No
Enumeration Date:2022-07-01
Last Update Date:2024-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2372252363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics