Provider Demographics
NPI:1962621433
Name:CANCELLIERI, MARY E (APRN,BC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:CANCELLIERI
Suffix:
Gender:F
Credentials:APRN,BC
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ELLEN
Other - Last Name:CANCELLIERI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APRN,BC
Mailing Address - Street 1:15 LAWRENCE ST
Mailing Address - Street 2:
Mailing Address - City:GARDNER
Mailing Address - State:MA
Mailing Address - Zip Code:01440-2337
Mailing Address - Country:US
Mailing Address - Phone:978-632-0918
Mailing Address - Fax:978-731-4220
Practice Address - Street 1:289 GREAT RD
Practice Address - Street 2:
Practice Address - City:ACTON
Practice Address - State:MA
Practice Address - Zip Code:01720-4766
Practice Address - Country:US
Practice Address - Phone:978-679-1225
Practice Address - Fax:978-486-4037
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2018-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA163573163WA0400X, 163WP0809X, 364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
No163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult