Provider Demographics
NPI:1790810257
Name:HETTICH-KELLY, MARY ANN (APRN CNS PSYCH)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:HETTICH-KELLY
Suffix:
Gender:F
Credentials:APRN CNS PSYCH
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ANN
Other - Last Name:HETTICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:259 NORTH ST # A
Mailing Address - Street 2:
Mailing Address - City:HYANNIS
Mailing Address - State:MA
Mailing Address - Zip Code:02601-3834
Mailing Address - Country:US
Mailing Address - Phone:508-862-0514
Mailing Address - Fax:508-862-9184
Practice Address - Street 1:259 NORTH ST # A
Practice Address - Street 2:
Practice Address - City:HYANNIS
Practice Address - State:MA
Practice Address - Zip Code:02601-3834
Practice Address - Country:US
Practice Address - Phone:508-862-0514
Practice Address - Fax:508-862-0514
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2025-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA197116363LF0000X, 364SP0812X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0812XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Community
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANP2460Medicare ID - Type Unspecified
MAP07612Medicare UPIN