Healthcare Provider Details

I. General information

NPI: 1285344523
Provider Name (Legal Business Name): JESSICA R DONOVAN FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2022
Last Update Date: 01/04/2023
Certification Date: 12/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 SCHUMAN AVE
AUGUSTA ME
04330-0433
US

IV. Provider business mailing address

71 MATTSON HTS
GARDINER ME
04345-2810
US

V. Phone/Fax

Practice location:
  • Phone: 207-307-0958
  • Fax:
Mailing address:
  • Phone: 207-554-0741
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP221637
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: