Healthcare Provider Details

I. General information

NPI: 1366488892
Provider Name (Legal Business Name): MICHELLE A GARDNER FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELLE A. HARRIS FNP-BC

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 04/10/2020
Certification Date: 04/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

489 STATE ST
BANGOR ME
04401-6616
US

IV. Provider business mailing address

43 WHITING HILL RD SUITE 300
BREWER ME
04412-1005
US

V. Phone/Fax

Practice location:
  • Phone: 207-973-7000
  • Fax: 207-973-7394
Mailing address:
  • Phone: 207-973-5035
  • Fax: 207-973-5042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License NumberR032905
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP081584
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: