Provider Demographics
NPI:1790013910
Name:STACKPOOLE, MARI AGNES (NP)
Entity Type:Individual
Prefix:MISS
First Name:MARI
Middle Name:AGNES
Last Name:STACKPOOLE
Suffix:
Gender:F
Credentials:NP
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Other - Credentials:
Mailing Address - Street 1:1261 FURNACE BROOK PKWY
Mailing Address - Street 2:SUITE 30-31
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-4721
Mailing Address - Country:US
Mailing Address - Phone:617-479-4545
Mailing Address - Fax:617-479-4555
Practice Address - Street 1:1261 FURNACE BROOK PKWY
Practice Address - Street 2:SUITE 30-31
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-4721
Practice Address - Country:US
Practice Address - Phone:617-479-4545
Practice Address - Fax:617-479-4555
Is Sole Proprietor?:No
Enumeration Date:2009-11-28
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA280880163W00000X, 363LG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA001530001Medicare PIN