Healthcare Provider Details

I. General information

NPI: 1174809412
Provider Name (Legal Business Name): JENNIFER WYNNE TAYLOR PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2011
Last Update Date: 11/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

268 STILLWATER AVE
BANGOR ME
04401-3945
US

IV. Provider business mailing address

268 STILLWATER AVE PO BOX 422
BANGOR ME
04401-3945
US

V. Phone/Fax

Practice location:
  • Phone: 207-973-6100
  • Fax: 207-973-6109
Mailing address:
  • Phone: 207-973-6100
  • Fax: 207-973-6109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP111088
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: