Provider Demographics
NPI:1154312825
Name:COLLIER, MARY L (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:COLLIER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 HARRISON AVE
Mailing Address - Street 2:DOB 503
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2371
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:725 ALBANY STREET
Practice Address - Street 2:SHAPIRO 8
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118
Practice Address - Country:US
Practice Address - Phone:617-638-7420
Practice Address - Fax:617-638-7289
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN166148363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110024852AMedicaid
Q43877Medicare UPIN
MA110024852AMedicaid