MEDICARE: MARY S BANNON NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LG0600X	Gerontology Nurse Practitioner	158347	MA

General Provider Information

NPI Number	:	1043392590
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY S BANNON NP

Provider Business Mailing Address
First Line	:	47 HIGH STREET SUITE 101
Second Line	:
City	:	NORTH ANDOVER
State	:	MA
Zip	:	01845
Country	:	US
Telephone Number	:	978-685-2460
Fax Number	:	978-685-2572

Provider Business Practice Location Address
First Line	:	671 MAIN ST
Second Line	:
City	:	WALTHAM
State	:	MA
Zip	:	02451-0602
Country	:	US
Telephone Number	:	781-647-3040
Fax Number	:	781-647-3044

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/20/2006
Last Update Date	:	07/28/2017

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