| Doctor Name: | MARY S BANNON |
| NPI Number: | 1043392590 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | NP |
| License Number: | 158347 |
| Business Practice Address: | 671 Main St Waltham, MA - 024510602 |
| Business Phone Number: | 7816473040 |
| Business Fax Number: | 7816473044 |
| Mailing Address: | 671 Main St, WALTHAM |
| State: | MA |
| Postal Code: | 024510602 |
| Phone Number: | 6176473040 |
| Fax Number: | 6176473044 |
| NPI Enumeration Date: | 10/20/2006 |
| NPI Last Update Date: | 03/26/2010 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363LG0600X |
| License Number: | 158347 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MA |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Nurse Practitioner |
| Taxonomy Specialization: | Gerontology |
| Taxonomy Definition: | |