Healthcare Provider Details

I. General information

NPI: 1386866879
Provider Name (Legal Business Name): DIANE M. MAZEROLLE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CUMBERLAND PL STE 108
BANGOR ME
04401-5087
US

IV. Provider business mailing address

20 OAK STREET
KENDUSKEAG ME
04450
US

V. Phone/Fax

Practice location:
  • Phone: 207-990-9000
  • Fax: 207-945-8645
Mailing address:
  • Phone: 207-884-6068
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number018634
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: