Provider Demographics
NPI:1568438729
Name:CASSIDY, MARY C (NP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:C
Last Name:CASSIDY
Suffix:
Gender:F
Credentials:NP
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Mailing Address - Street 1:90 READVILLE ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02136-2040
Mailing Address - Country:US
Mailing Address - Phone:617-361-1173
Mailing Address - Fax:617-361-1173
Practice Address - Street 1:11 KENT ST
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02445-7901
Practice Address - Country:US
Practice Address - Phone:617-447-2147
Practice Address - Fax:617-264-9763
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA129190363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0347001Medicaid
MANP2539OtherBCBS
MA0347001Medicaid