Basic Information
| Provider Information | |||||||||
| NPI: | 1790013910 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STACKPOOLE | ||||||||
| FirstName: | MARI | ||||||||
| MiddleName: | AGNES | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1261 FURNACE BROOK PKWY | ||||||||
| Address2: | SUITE 30-31 | ||||||||
| City: | QUINCY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021694721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174794545 | ||||||||
| FaxNumber: | 6174794555 | ||||||||
| Practice Location | |||||||||
| Address1: | 1261 FURNACE BROOK PKWY | ||||||||
| Address2: | SUITE 30-31 | ||||||||
| City: | QUINCY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021694721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174794545 | ||||||||
| FaxNumber: | 6174794555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2009 | ||||||||
| LastUpdateDate: | 01/09/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 280880 | MA | N | Nursing Service Providers | Registered Nurse | 363LG0600X | 280880 | MA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363LA2200X | 280880 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.