Provider Demographics
NPI:1447365515
Name:CONNOLLY, MARY R (NP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:R
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 WALL ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01803-4758
Mailing Address - Country:US
Mailing Address - Phone:781-221-2600
Mailing Address - Fax:
Practice Address - Street 1:20 WALL ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01803-4758
Practice Address - Country:US
Practice Address - Phone:781-221-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA113932363LA2200X
CO169627363LC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity Health