Healthcare Provider Details

I. General information

NPI: 1578584843
Provider Name (Legal Business Name): MARY LOU RYAN RNCS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 10/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 HOLLAND ST
SOMERVILLE MA
02144-2705
US

IV. Provider business mailing address

40 HOLLAND ST HVMA
SOMERVILLE MA
02144-2705
US

V. Phone/Fax

Practice location:
  • Phone: 617-629-6180
  • Fax:
Mailing address:
  • Phone: 617-629-6180
  • Fax: 617-629-6041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number150000
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: