Healthcare Provider Details

I. General information

NPI: 1962721910
Provider Name (Legal Business Name): MARY KOWAL RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2010
Last Update Date: 05/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

486 WORCESTER ST KENNEDY DONOVAN CENTER
SOUTHBRIDGE MA
01550-1386
US

IV. Provider business mailing address

486 WORCESTER ST KENNEDY DONOVAN CENTER
SOUTHBRIDGE MA
01550-1386
US

V. Phone/Fax

Practice location:
  • Phone: 508-765-0292
  • Fax:
Mailing address:
  • Phone: 508-765-0292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN2263083
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: