Basic Information
Provider Information | |||||||||
NPI: | 1356484265 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CREELY | ||||||||
FirstName: | MARY JANE | ||||||||
MiddleName: | T | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MS, RN, PCNS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 127 JOHNNY CAKE HILL RD | ||||||||
Address2: |   | ||||||||
City: | MIDDLETOWN | ||||||||
State: | RI | ||||||||
PostalCode: | 028425674 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4018461213 | ||||||||
FaxNumber: | 4018489151 | ||||||||
Practice Location | |||||||||
Address1: | 127 JOHNNY CAKE HILL RD | ||||||||
Address2: |   | ||||||||
City: | MIDDLETOWN | ||||||||
State: | RI | ||||||||
PostalCode: | 028425674 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4018461213 | ||||||||
FaxNumber: | 4018489151 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/14/2007 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SP0809X | PNS00002 | RI | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health, Adult |
ID Information
ID | Type | State | Issuer | Description | MC14017 | 05 | RI |   | MEDICAID |