Healthcare Provider Details

I. General information

NPI: 1962621433
Provider Name (Legal Business Name): MARY E CANCELLIERI APRN,BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY ELLEN CANCELLIERI APRN,BC

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 02/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

289 GREAT RD
ACTON MA
01720-4766
US

IV. Provider business mailing address

15 LAWRENCE ST
GARDNER MA
01440-2337
US

V. Phone/Fax

Practice location:
  • Phone: 978-679-1225
  • Fax: 978-486-4037
Mailing address:
  • Phone: 978-632-0918
  • Fax: 978-731-4220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number163573
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number163573
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number163573
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: