Healthcare Provider Details

I. General information

NPI: 1649477373
Provider Name (Legal Business Name): CAROL ANN CLANCY RNC MSN ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CAROL ANN DONOVAN LN

II. Dates (important events)

Enumeration Date: 06/27/2007
Last Update Date: 08/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 HARRISON AVE FL 7
BOSTON MA
02118-2371
US

IV. Provider business mailing address

60 CENTURY DR
CANTON MA
02021-3636
US

V. Phone/Fax

Practice location:
  • Phone: 617-414-8261
  • Fax: 617-638-8406
Mailing address:
  • Phone: 781-828-2286
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0106X
TaxonomyOccupational Health Nurse Practitioner
License Number181036
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: