Provider Demographics
NPI:1790810257
Name:HETTICH-KELLY, MARY ANN (APRN CNS PSYCH)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:HETTICH-KELLY
Suffix:
Gender:F
Credentials:APRN CNS PSYCH
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ANN
Other - Last Name:HETTICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:118 WATERHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:BUZZARDS BAY
Mailing Address - State:MA
Mailing Address - Zip Code:02532-8305
Mailing Address - Country:US
Mailing Address - Phone:508-743-0899
Mailing Address - Fax:508-477-7028
Practice Address - Street 1:118 WATERHOUSE RD
Practice Address - Street 2:
Practice Address - City:BUZZARDS BAY
Practice Address - State:MA
Practice Address - Zip Code:02532-8305
Practice Address - Country:US
Practice Address - Phone:508-743-0899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA197116364SP0812X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No364SP0812XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Community
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANP2460Medicare ID - Type Unspecified
MAP07612Medicare UPIN