Provider Demographics
NPI:1518278910
Name:MCDONOUGH, MARYANN (APRN)
Entity Type:Individual
Prefix:MRS
First Name:MARYANN
Middle Name:
Last Name:MCDONOUGH
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 YORK ST, CB-2041
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-3220
Mailing Address - Country:US
Mailing Address - Phone:203-688-4242
Mailing Address - Fax:
Practice Address - Street 1:20 YORK ST, CB-2041
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3220
Practice Address - Country:US
Practice Address - Phone:203-688-4748
Practice Address - Fax:203-688-4740
Is Sole Proprietor?:No
Enumeration Date:2010-06-30
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5794363L00000X, 363LA2200X
NY351656163W00000X, 163WH0200X, 163WI0500X, 163WP0200X, 163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WI0500XNursing Service ProvidersRegistered NurseInfusion Therapy
No163WP0200XNursing Service ProvidersRegistered NursePediatrics
No163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care