Provider Demographics
NPI:1770686313
Name:MASSONNE, MARY LYNN (MS APRN FNP BC)
Entity Type:Individual
Prefix:MR
First Name:MARY
Middle Name:LYNN
Last Name:MASSONNE
Suffix:
Gender:F
Credentials:MS APRN FNP BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2090 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLTON
Mailing Address - State:NY
Mailing Address - Zip Code:12019
Mailing Address - Country:US
Mailing Address - Phone:518-399-3963
Mailing Address - Fax:
Practice Address - Street 1:2554 RT 9
Practice Address - Street 2:
Practice Address - City:MALTA
Practice Address - State:NY
Practice Address - Zip Code:12020
Practice Address - Country:US
Practice Address - Phone:518-899-5002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF332837363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYMM1181750OtherDEA
RA5974Medicare ID - Type Unspecified
Q38028Medicare UPIN