Healthcare Provider Details

I. General information

NPI: 1003055294
Provider Name (Legal Business Name): THERESA ANNE YOUNG RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2009
Last Update Date: 02/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 BROADWAY
BANGOR ME
04401-3979
US

IV. Provider business mailing address

71 ADAMS RD
FRANKFORT ME
04438-3331
US

V. Phone/Fax

Practice location:
  • Phone: 207-525-4526
  • Fax:
Mailing address:
  • Phone: 207-525-4526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR054148
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: