Provider Demographics
NPI:1578584843
Name:RYAN, MARY LOU (RNCS)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LOU
Last Name:RYAN
Suffix:
Gender:F
Credentials:RNCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 HOLLAND ST
Mailing Address - Street 2:HVMA
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02144-2705
Mailing Address - Country:US
Mailing Address - Phone:617-629-6180
Mailing Address - Fax:617-629-6041
Practice Address - Street 1:40 HOLLAND ST
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02144-2705
Practice Address - Country:US
Practice Address - Phone:617-629-6180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-22
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA150000163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0036952OtherNEIGHBORHOOD HEALTH PLAN
MA669498OtherTUFTS HEALTH PLAN
MAPN0575OtherBLUE CROSS
MANS0125Medicare ID - Type Unspecified