Healthcare Provider Details

I. General information

NPI: 1477706331
Provider Name (Legal Business Name): BRENDA COTTLE DEBLOIS RN-CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

1 VA CTR
AUGUSTA ME
04330-6719
US

IV. Provider business mailing address

1 VA CTR
AUGUSTA ME
04330-6719
US

V. Phone/Fax

Practice location:
  • Phone: 207-622-9678
  • Fax: 207-623-5719
Mailing address:
  • Phone: 207-622-9678
  • Fax: 207-623-5719

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License NumberR027281
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: