Provider Demographics
NPI:1801872023
Name:LUCCI, MARY EDITH (CRNA)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:EDITH
Last Name:LUCCI
Suffix:
Gender:
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 MASSACHUSETTS AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2690
Mailing Address - Country:US
Mailing Address - Phone:617-414-5405
Mailing Address - Fax:617-789-3015
Practice Address - Street 1:235 N PEARL ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-1794
Practice Address - Country:US
Practice Address - Phone:508-427-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNA-00184367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00949833OtherMEDICARE RAILROAD
OH0157682Medicaid
OHLU8219237Medicare PIN