Provider Demographics
NPI:1659563179
Name:DISTASIO, MARY ELLEN
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELLEN
Last Name:DISTASIO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 VICTORY RD
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02171-3139
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 VICTORY RD
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02171-3139
Practice Address - Country:US
Practice Address - Phone:617-847-1950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-17
Last Update Date:2016-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program