MEDICARE: MS. MARY L MCKENNEY 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	363LA2200X	Adult Health Nurse Practitioner	168445	MA

General Provider Information

NPI Number	:	1184647604
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY L MCKENNEY NP

Provider Business Mailing Address
First Line	:	102 PINE ST
Second Line	:
City	:	QUINCY
State	:	MA
Zip	:	02170-1208
Country	:	US
Telephone Number	:	617-632-3233
Fax Number	:	617-632-6665

Provider Business Practice Location Address
First Line	:	102 PINE ST
Second Line	:
City	:	QUINCY
State	:	MA
Zip	:	02170-1208
Country	:	US
Telephone Number	:	617-632-3233
Fax Number	:	617-632-6665

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

Provider Enumeration Date	:	07/25/2006
Last Update Date	:	07/08/2007

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