MEDICARE: MARIANNE DECAIN TARRAZA NP, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WP0809X	Adult Psychiatric/Mental Health Registered Nurse	CNP81164	ME

General Provider Information

NPI Number	:	1932454907
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARIANNE DECAIN TARRAZA NP, LLC

Provider Business Mailing Address
First Line	:	PO BOX 2328
Second Line	:
City	:	SOUTH PORTLAND
State	:	ME
Zip	:	04116-2328
Country	:	US
Telephone Number	:	207-312-1063
Fax Number	:	207-375-5165

Provider Business Practice Location Address
First Line	:	1000 SHORE RD
Second Line	:	BUILDING #326
City	:	CAPE ELIZABETH
State	:	ME
Zip	:	04107-1916
Country	:	US
Telephone Number	:	207-312-1063
Fax Number	:	207-375-5165

Authorized Official
Title or Position	:	CREDENTIALING BILLING REP
Name	:	JENNIFER S FOURNIER
Credential	:
Telephone Number	:	207-312-1063

Provider Enumeration Date	:	07/17/2012
Last Update Date	:	07/17/2012

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