Provider Demographics
NPI:1285631424
Name:LAVIN, MARY D (RNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:D
Last Name:LAVIN
Suffix:
Gender:F
Credentials:RNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 ELLENFIELD ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-4513
Mailing Address - Country:US
Mailing Address - Phone:401-444-4318
Mailing Address - Fax:401-444-6573
Practice Address - Street 1:20 SOUTHWEST AVE
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:RI
Practice Address - Zip Code:02835-1120
Practice Address - Country:US
Practice Address - Phone:401-423-2616
Practice Address - Fax:401-423-3485
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RINPP20913363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI409407OtherRI BLUE CHIP
RIML42620Medicaid
RI23638-6OtherRI BC/BS
RI23638-6OtherRI BC/BS
007006679Medicare ID - Type Unspecified