Provider Demographics
NPI:1720095086
Name:LIGHT, MARY ANN (APN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:LIGHT
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 772
Mailing Address - Street 2:
Mailing Address - City:WOONSOCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02895-0784
Mailing Address - Country:US
Mailing Address - Phone:401-770-5779
Mailing Address - Fax:401-652-9787
Practice Address - Street 1:796 RIDGEWAY AVE
Practice Address - Street 2:
Practice Address - City:SIGNAL MOUNTAIN
Practice Address - State:TN
Practice Address - Zip Code:37377-3067
Practice Address - Country:US
Practice Address - Phone:423-886-3269
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-052430363L00000X
TN12784363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051530068OtherBC BOAZ
AL891010020Medicaid
AL051530066OtherBC FORT PAYNE
AL891010030Medicaid
AL051530066OtherBC FORT PAYNE
AL051530068OtherBC BOAZ
TN3341381Medicare PIN