Provider Demographics
NPI:1720245780
Name:KELLY, MARY DANA (CPNP)
Entity Type:Individual
Prefix:MISS
First Name:MARY
Middle Name:DANA
Last Name:KELLY
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:300 LONGWOOD AVENUE
Mailing Address - Street 2:CHPCC HUNNEWELL GROUND
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115
Mailing Address - Country:US
Mailing Address - Phone:617-355-7701
Mailing Address - Fax:
Practice Address - Street 1:300 LONGWOOD AVE
Practice Address - Street 2:CHPCC HUNNEWELL GROUND
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115
Practice Address - Country:US
Practice Address - Phone:617-355-7701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-19
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA152018363LP0200X, 364SP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No364SP0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPediatrics