Healthcare Provider Details

I. General information

NPI: 1285887158
Provider Name (Legal Business Name): MARY ANN BOULOS-LORD NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2008
Last Update Date: 10/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 HARRIS ST
AUBURN ME
04210-4671
US

IV. Provider business mailing address

PO BOX 4140
BOSTON MA
02241-0001
US

V. Phone/Fax

Practice location:
  • Phone: 207-782-6827
  • Fax: 207-376-0090
Mailing address:
  • Phone: 207-777-4111
  • Fax: 207-783-6660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR037527
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License NumberR037527
License Number StateME
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP081959
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: