Provider Demographics
NPI:1538136338
Name:GLOVER, MARY (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:GLOVER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 NORTHAMPTON STREET
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-4010
Mailing Address - Country:US
Mailing Address - Phone:617-433-9601
Mailing Address - Fax:617-445-6538
Practice Address - Street 1:30 NORTHAMPTON STREET
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-4010
Practice Address - Country:US
Practice Address - Phone:617-433-9601
Practice Address - Fax:617-445-6538
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA122517363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0344711Medicaid
MAGLNP1279Medicare ID - Type Unspecified
MA0344711Medicaid