Healthcare Provider Details

I. General information

NPI: 1972911824
Provider Name (Legal Business Name): MARIANNE T CANNON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2014
Last Update Date: 11/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CUMMINGS CTR STE 345F
BEVERLY MA
01915-6501
US

IV. Provider business mailing address

100 CUMMINGS CTR STE 345F
BEVERLY MA
01915-6501
US

V. Phone/Fax

Practice location:
  • Phone: 978-535-6043
  • Fax: 978-535-6047
Mailing address:
  • Phone: 978-535-6043
  • Fax: 978-535-6047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License NumberRN101598
License Number StateMA

VIII. Authorized Official

Name: ANN MARIE MCGRANE
Title or Position: OFFICE MANAGER
Credential:
Phone: 978-535-6043