Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2084N0402X | Child Neurologist | 2020008135 | MO |
Y | 2084N0402X | Child Neurologist | 287832 | MA |
NPI | 1073994216 |
---|---|
Provider Name | Kimberly Wiltrout |
First Address | Boston, MA 02115-5724 |
Second Address | Boston, MA 02115-5724 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/06/2015 |
Last Update Date | 01/02/2022 |