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:
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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:
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Provider Licenses
StateLicense IDTaxonomies
MA254446364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
N50709Medicare ID - Type Unspecified
Q07062Medicare UPIN