Healthcare Provider Details

I. General information

NPI: 1043756489
Provider Name (Legal Business Name): ELIZABETH CHESNUT APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2017
Last Update Date: 11/02/2021
Certification Date: 11/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 E CHESTNUT ST
AUGUSTA ME
04330-5758
US

IV. Provider business mailing address

6 E CHESTNUT ST
AUGUSTA ME
04330-5758
US

V. Phone/Fax

Practice location:
  • Phone: 207-626-7400
  • Fax: 207-626-7401
Mailing address:
  • Phone: 207-626-7400
  • Fax: 207-626-7401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041416041
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209014946
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberCNP211476
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: