Provider Demographics
NPI:1912129917
Name:BUCKLEY CYR, MARYELLEN B (NP)
Entity type:Individual
Prefix:MS
First Name:MARYELLEN
Middle Name:B
Last Name:BUCKLEY CYR
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:MARYELLEN
Other - Middle Name:B
Other - Last Name:CYR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:77 MASS AVE E 23-230
Mailing Address - Street 2:MIT MEDICAL
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139
Mailing Address - Country:US
Mailing Address - Phone:617-253-4431
Mailing Address - Fax:617-355-4085
Practice Address - Street 1:287 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:ALLSTON
Practice Address - State:MA
Practice Address - Zip Code:02134-1010
Practice Address - Country:US
Practice Address - Phone:617-783-0500
Practice Address - Fax:617-783-5514
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA122618363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care