MEDICARE: MARY A HANNON A PRN

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	364SP0809X	Adult Psychiatric/Mental Health Clinical Nurse Specialist	254446	MA

General Provider Information

NPI Number	:	1467402586
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY A HANNON A PRN

Provider Business Mailing Address
First Line	:	30 HIGGINS CROWELL RD
Second Line	:	PSYCHIATRIC COLLABORATIVE
City	:	WEST YARMOUTH
State	:	MA
Zip	:	02673-3444
Country	:	US
Telephone Number	:	508-240-7964
Fax Number	:	508-778-8581

Provider Business Practice Location Address
First Line	:	30 HIGGINS CROWELL RD
Second Line	:	PSYCHIATRIC COLLABORATIVE
City	:	WEST YARMOUTH
State	:	MA
Zip	:	02673-3444
Country	:	US
Telephone Number	:	508-240-7964
Fax Number	:	508-778-8581

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

Provider Enumeration Date	:	05/11/2006
Last Update Date	:	03/12/2013

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