Provider Demographics
NPI:1235778986
Name:ETHEREDGE, MARY LOU (PCNS-BC)
Entity Type:Individual
Prefix:
First Name:MARY LOU
Middle Name:
Last Name:ETHEREDGE
Suffix:
Gender:F
Credentials:PCNS-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 OAK HILL RD
Mailing Address - Street 2:
Mailing Address - City:NATICK
Mailing Address - State:MA
Mailing Address - Zip Code:01760-1009
Mailing Address - Country:US
Mailing Address - Phone:617-877-0371
Mailing Address - Fax:
Practice Address - Street 1:5 OAK HILL RD
Practice Address - Street 2:
Practice Address - City:NATICK
Practice Address - State:MA
Practice Address - Zip Code:01760-1009
Practice Address - Country:US
Practice Address - Phone:617-877-0371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-29
Last Update Date:2019-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN111702163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult