1649477373 NPI number — MRS. CAROL ANN CLANCY RNC MSN ANP

Table of content: (NPI 1780141085)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649477373 NPI number — MRS. CAROL ANN CLANCY RNC MSN ANP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLANCY
Provider First Name:
CAROL
Provider Middle Name:
ANN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RNC MSN ANP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DONOVAN
Provider Other First Name:
CAROL
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
LN
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1649477373
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/07/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
60 CENTURY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02021-3636
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-828-2286
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
720 HARRISON AVE FL 7
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02118-2371
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-414-8261
Provider Business Practice Location Address Fax Number:
617-638-8406
Provider Enumeration Date:
06/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LX0106X , with the licence number:  181036 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0327565 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com