Provider Demographics
NPI:1104949247
Name:STANLEY, MARY K
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:STANLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:K
Other - Last Name:STANLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS,RN,NP
Mailing Address - Street 1:PO BOX 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:800-225-8885
Mailing Address - Fax:
Practice Address - Street 1:55 LAKE AVE N
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:508-334-3452
Practice Address - Fax:774-442-5440
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA160267363L00000X
MARN160267363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110085661AMedicaid