Provider Demographics
NPI:1831109040
Name:GAGNE, MARY LEE (APRN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LEE
Last Name:GAGNE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:LEE
Other - Last Name:GIBBS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:27 PARK ST
Mailing Address - Street 2:PSYCH CENTER
Mailing Address - City:HYANNIS
Mailing Address - State:MA
Mailing Address - Zip Code:02601-5230
Mailing Address - Country:US
Mailing Address - Phone:508-862-5845
Mailing Address - Fax:508-862-7387
Practice Address - Street 1:27 PARK ST
Practice Address - Street 2:PSYCH CENTER
Practice Address - City:HYANNIS
Practice Address - State:MA
Practice Address - Zip Code:02601-5230
Practice Address - Country:US
Practice Address - Phone:508-862-5845
Practice Address - Fax:508-862-7387
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA166065364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health