Provider Demographics
NPI:1255768628
Name:WITHEY, MARY BOSS (APRN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:BOSS
Last Name:WITHEY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 MANSFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:WILLIMANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06226-2045
Mailing Address - Country:US
Mailing Address - Phone:860-456-9116
Mailing Address - Fax:
Practice Address - Street 1:141 TUCKIE RD
Practice Address - Street 2:
Practice Address - City:NORTH WINDHAM
Practice Address - State:CT
Practice Address - Zip Code:06256-1317
Practice Address - Country:US
Practice Address - Phone:860-465-2610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-01
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001190363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily