Healthcare Provider Details

I. General information

NPI: 1962937417
Provider Name (Legal Business Name): TINA MARIE BLACKLEY APRN FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2017
Last Update Date: 12/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 BROADWAY
BANGOR ME
04401
US

IV. Provider business mailing address

C/O ST MARYS HEALTH SYSTEM - PROVIDER ENROLLMENT PO BOX 7291
LEWISTON ME
04243-7291
US

V. Phone/Fax

Practice location:
  • Phone: 207-907-3300
  • Fax: 207-907-1923
Mailing address:
  • Phone: 207-777-8560
  • Fax: 207-777-8800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP171038
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: