Provider Demographics
NPI:1053366963
Name:INNIS, MARY R (RN PC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:R
Last Name:INNIS
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Gender:F
Credentials:RN PC
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Mailing Address - Street 1:PO BOX 415348 PROVIDER ENROLLMENT
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:800-225-8885
Mailing Address - Fax:508-334-1977
Practice Address - Street 1:100 CENTURY DR
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01606
Practice Address - Country:US
Practice Address - Phone:508-762-5400
Practice Address - Fax:508-762-5410
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2020-11-24
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Provider Licenses
StateLicense IDTaxonomies
MA167110364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS71314Medicare UPIN
MANS 0232Medicare PIN