Provider Demographics
NPI:1366612970
Name:HARRIS, MARY R (APRN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:R
Last Name:HARRIS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 ATLANTIC ST
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-6805
Mailing Address - Country:US
Mailing Address - Phone:203-327-5111
Mailing Address - Fax:203-327-2991
Practice Address - Street 1:805 ATLANTIC ST
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-6805
Practice Address - Country:US
Practice Address - Phone:203-327-5111
Practice Address - Fax:203-327-2991
Is Sole Proprietor?:No
Enumeration Date:2008-03-11
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003718363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT003718OtherSTATE LICENSE
CT003718OtherSTATE LICENSE