Provider Demographics
NPI:1841375607
Name:SCANLON, MARY LOUISE (RNCS)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LOUISE
Last Name:SCANLON
Suffix:
Gender:F
Credentials:RNCS
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:LOUISE
Other - Last Name:SCANLON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP
Mailing Address - Street 1:26 CENTRAL ST
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02143-2827
Mailing Address - Country:US
Mailing Address - Phone:617-591-6300
Mailing Address - Fax:617-591-6435
Practice Address - Street 1:26 CENTRAL ST
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02143-2827
Practice Address - Country:US
Practice Address - Phone:617-591-6300
Practice Address - Fax:617-591-6435
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2009-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA216316163W00000X, 364SP0809X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
MASC-NP3046Medicare PIN