Provider Demographics
NPI:1023592896
Name:KOLVATZ, TYLER ANNE
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:ANNE
Last Name:KOLVATZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 DAWES TER APT 2
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02125-1720
Mailing Address - Country:US
Mailing Address - Phone:617-894-0443
Mailing Address - Fax:
Practice Address - Street 1:780 ALBANY ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2755
Practice Address - Country:US
Practice Address - Phone:857-654-1000
Practice Address - Fax:857-654-1100
Is Sole Proprietor?:No
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2312117163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice