Provider Demographics
NPI: | 1467402586 |
---|---|
Name: | HANNON, MARY A (A PRN) |
Entity Type: | Individual |
Prefix: | |
First Name: | MARY |
Middle Name: | A |
Last Name: | HANNON |
Suffix: | |
Gender: | F |
Credentials: | A PRN |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 30 HIGGINS CROWELL RD |
Mailing Address - Street 2: | PSYCHIATRIC COLLABORATIVE |
Mailing Address - City: | WEST YARMOUTH |
Mailing Address - State: | MA |
Mailing Address - Zip Code: | 02673-3444 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 508-240-7964 |
Mailing Address - Fax: | 508-778-8581 |
Practice Address - Street 1: | 30 HIGGINS CROWELL RD |
Practice Address - Street 2: | PSYCHIATRIC COLLABORATIVE |
Practice Address - City: | WEST YARMOUTH |
Practice Address - State: | MA |
Practice Address - Zip Code: | 02673-3444 |
Practice Address - Country: | US |
Practice Address - Phone: | 508-240-7964 |
Practice Address - Fax: | 508-778-8581 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2006-05-11 |
Last Update Date: | 2013-03-12 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MA | 254446 | 364SP0809X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 364SP0809X | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psychiatric/Mental Health, Adult |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
N50709 | Medicare ID - Type Unspecified | ||
Q07062 | Medicare UPIN |