Provider Demographics
NPI:1245290725
Name:CORONADO, MARY ELLEN
Entity type:Individual
Prefix:
First Name:MARY ELLEN
Middle Name:
Last Name:CORONADO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY ELLEN
Other - Middle Name:
Other - Last Name:RICCARDI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:490 BOSTON POST RD STE 2001
Mailing Address - Street 2:
Mailing Address - City:SUDBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01776-3392
Mailing Address - Country:US
Mailing Address - Phone:789-579-6018
Mailing Address - Fax:
Practice Address - Street 1:490 BOSTON POST RD STE 2001
Practice Address - Street 2:
Practice Address - City:SUDBURY
Practice Address - State:MA
Practice Address - Zip Code:01776-3392
Practice Address - Country:US
Practice Address - Phone:785-796-0189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA156838363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0365980Medicaid
MA0365980Medicaid
MAP39321Medicare UPIN