Healthcare Provider Details

I. General information

NPI: 1255871240
Provider Name (Legal Business Name): COURTNEY LEE TAYLOR AGACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2017
Last Update Date: 10/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 STATE ST WEBBER EAST, SUITE 421
BANGOR ME
04401-6630
US

IV. Provider business mailing address

43 WHITING HILL RD STE 300
BREWER ME
04412-1006
US

V. Phone/Fax

Practice location:
  • Phone: 207-973-5293
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberCNP171008
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: